A total of 31 patients, (20 women, 11 men; mean
age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone
resection-arthroplasty (RA) to a total hip replacement (THR) were
compared with 93 patients, (60 women, 33 men; mean age 63.4 years
old; 20 to 89), who had revision THR surgery for aseptic loosening
in a retrospective matched case-control study. Age, gender and the
extent of the pre-operative bone defect were similar in all patients.
Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the
control group (p = 0.01 and 0.003, respectively) and pre-operative
leg length discrepancy (LLD) was greater in the RA group (p <
0.001). The post-operative clinical outcome was similar in both
groups except for mean post-operative LLD, which was greater in
the study group (p = 0.003). There was a significant interaction
effect for LLD in the study group (p <
0.001). A two-way analysis
of variance showed that clinical outcome depended on patient age
(patients older than 70 years old had worse pre-operative pain,
p = 0.017) or bone defect (patients with a large acetabular bone
defect had higher LLD, p = 0.006, worse post-operative function
p = 0.009 and range of movement, p = 0.005), irrespective of the
group. Despite major acetabular and femoral bone defects requiring complex
surgical reconstruction techniques, THR after RA shows a clinical
outcome similar to those obtained in aseptic revision surgery for
hips with similar sized bone defects. Cite this article:
Introduction. Biological repair of acetabular bone defects after impaction bone grafting (IBG) in total hip arthroplasty could facilitate future re-revisions in case of failure of the reconstruction again using the same technique. Few studies have analysed the outcome of these acetabular re-revisions. Patients and Methods. We analysed 34 consecutive acetabular re-revisions that repeated IBG and a cemented cup in a cohort of 330 acetabular IBG revisions. Fresh-frozen femoral head allografts were morselized manually. All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. The mean follow-up after re-revision was 7.2 years (2–17). Intraoperative bone defect had lessened after the first failed revision. At the first revision there were 14 hips with Paprosky 3A and 20 with Paprosky type 3B. At the re-revision there were 5 hips with Paproky 2B, 21 with Paprosky type 3A and 8 with type 3B. Lateral mesh was used in 19 hips. Results. The mean Harris Hip Score improved from 45.4 (6.7) to 77.1 (15.6) at final follow-up. The radiological analysis showed cup migration in 11 hips. The mean appearance time was 25 months (3–72). Of these, migration in three cups was progressive and painful requiring re-revision. Cup tilt was found in all migrated hips. There were one dislocation requiring a cemented dual mobility cup associated with IBG and one infection resolved with
Introduction: In two-stage revision of an infected total hip replacement a preformed temporary antibiotic-loaded polymethylmethacrylate spacer may be required in order to allow weightbearing and joint motion while ensuring antibiotic local release. Methods: 29 patients with infected hips were treated by a two-stage procedure including removal of prosthesis and implantation of a spacer. The device comprised a stem with 3 available head sizes pre-coated by bone cement supplemented with gentamicin (2.5% w/w) and vancomycin (2.5% w/w). Joint motion and weight-bearing were allowed when the bone stock ensured an adequate stability to the spacer. Systemic antibiotics were administered for 8 weeks. The spacer remained in situ for an average of 155 (range 70–272) days. Reimplantation was performed when recovery of clinical and serological signs of infection was obtained. Patients’ evaluation included clinical assessment (HHS), standard x-ray and laboratory parameters. Results: mean follow-up was 52 months (range 36–100). Healing of the infection was obtained in 27/29 cases (93.1%). 5 patients required
Purpose: We report a retrospecitve series of 88 benign osteolytic tumours of the knee treated by curettage-filling between 1973 and 2000. The purpose of this analysis was to evaluate the role of curettage-filling in the treatment of this type of tumour. Material and methods: Mean patient age was 31 years. The sex ratio was 1. Pain was the main sign and 9% of patients had a pathologic fracture. An equivalent number of tumours were found in the lower extremity of the femur and the upper extremity of the tibia. We analysed clinical features, imaging findings, treatments and complications, recurrence, and treatment of recurrence. Results: Giant-cell tumours predominated (n=63), followed by aneurysmal cysts (n=7) and chondroblastomas (n=6). Tumours were treated by curettage associated with filling (n=83) and osteosynthesis (n=51). There were six cases of mechanical complications, but only two required total knee arthroplasty. No re-operations for arthrolysis were required. The recurrence rate after curettage was 23%; a second curettage-filling was performed after 90% of the recurrences. Discussion: This study confirms that curettage-filling is the standard surgical treatment for benign osteolytic tumours of the knee, independently of histological type. This simple procedure with a low complication rate enables preservation of the joint in young subjects. We prefer this approach to
Objective of study: Two-stage revision procedure of infected total hip replacements usually involves the application of a temporary antibiotic-loaded poly-methylmethacrylate spacer. A preformed spacer which allows weightbearing and joint motion while ensuring a sustained antibiotic release was evaluated. Material and Methods: 26 consecutive patients affected with an infected total hip arthroplasty were treated by the insertion of an industrially preformed temporary spacer (Spacer-G). This device comprises a cylindrical stainless-steel rod coated with bone cement supplemented with gentamicin (1.8% w/w) and vancomycin (2.5% w/w). Joint mobilization and assisted weight-bearing were permitted when bone stock allowed an adequate mechanical stability of the spacer. Reimplantation was performed when normalization of serological parameters was obtained. Patients’ evaluation included clinical assessment, standard x-ray and laboratory parameters. Results: The spacer remained in situ for an average of 155 (70-272) days allowing healing of the infection in 24 cases. 5 patients required
Introduction: In the two-stage revision procedure for infected total hip arthroplasty (THA), healing of the infection can be enhanced by using an antibiotic-loaded acrylic cement (ALAC) spacer. The spacer also acts as a temporary implant, preserving the gap between bone segments and a certain degree of joint motion. Materials and methods: Between 1995 and 2003, 19 infected THAs were surgically treated by two-stage revision procedures, using gentamicin-loaded spacers. The infections were sustained by Staph. aureus in 7 cases, Staph. aureus + Enterococcus faecalis in 1 case, Staph. epidermidis in 4 cases, Strept, agalactiae in 1 case and Strept, β-haemoliticus in 1 case. In 5 hips presenting with secreting fistulae, no causative microrganisms were isolated. Average interval between the two surgical stages was 5.5 months (range, 2 weeks to 13 months). Systemic antibiotics were administered to all patients for a minimum period of 6 weeks after removal of the infected implant. The revision stem was cemented in 5 patients and not cemented in 13 patients. All the acetabular components were uncemented. In one patient, the second stage procedure consisted exclusively in removal of the spacer and debridement, owing to persisting infection sustained by Staph. aureus + Staph. epidermidis. Results: Seventeen patients were evaluated at an average follow up of 42.3 months (range, 6 to 92 months). Recurrence of infection (Staph. aureus) occurred in 1 patient and was treated by
Purpose: To analyse prolonged combinations of oral intracellular-effective antibiotics plus two-stage exchange surgery for treatment of chronic THA and TKA infections. Materials and Methods: Definition of infected case: more than 3 months from surgery; multiple positive intraoperative cultures and/or active fistulae. 33 patients were treated from 1996 to 2002: 8 THA, 5 hip hemiarthroplasties, 20 TKA. Bacteriology: 24 Staphylococci of which 16 were methycillin-resistant, 7 multi-resistant Gram-negative, 2 Cory-nebacteriae; 7 polymicrobian. Antibiotic therapy: two simultaneous oral antibiotics, selected according to bacterial sensitivity and intracel-lular effectiveness (rifampin, ofloxacin, ciprofloxacin, levofloxacin, trimethoprim-sulfamethoxazole, fosfomicin, linezolid, doxiciclin), were used on an outpatient basis (between 1st and 2nd surgery, and after 2nd surgery until serological normalization). Patients received intravenous antibiotics and were in-hospital only for one week after surgery. Surgery: two-stage exchange with 2nd stage delayed until clinical and serological normalization. Healing of infection: absence of clinical, serological and radiological evidence of infection along all follow-up. Prospective follow-up: 24-96 months. Results: Healing of infection: 32/33 patients (97%). Treatment failure: 1 patient (TKA) (3%). THA: 8/8 infections healed: 1 Girdlestone patient (1st stage of exchange) rejected reimplantation; 7 two-stage exchange (good/excellent objective and subjective result). Hip hemiarthroplasty: 5/5 infections healed: 3 Girdlestone (1st stage of exchange surgery, 2nd stage rejected because of hemiplegia or Alzheimer); 2 two-stage exchange (good/excellent objective and subjective result). TKA: 19/20 infections healed: 3
Introduction: The management of periprosthetic osteolysis is a challenging problem in revision hip arthroplasty. Filling acetabular bone defects with structural allografts resulted in early failure due to resorption of the graft. The application in combination with reinforcement rings should promote bone incorporation as a result of reduced mechanical stresses. This study evaluates the long-term results in the treatment of acetabular deficiencies using bulk allografts supported with a Burch-Schneider Anti-Protrusio Cage (APC). Materials and Methods: From January 1992 to December 1995, 69 consecutive patients underwent revision surgery following periprosthetic osteolysis and aseptic loosening of the cup. Acetabular bone loss included IIIA and IIIB types according to Paproski classification. 12 patients died for unrelated causes with a well-functioning total hip arthroplasty in situ. 3 cases were lost at follow-up. The study group consisted of 56 hips in 54 patients. There were 11 males and 43 females, aged from 33 to 84 years (medium 65). Average follow-up was 11.7 years, ranging from 10 to 14.4. Surgical procedure included filling acetabular bone defects with bulk allografts supported with a Burch-Schneider APC which was fixed with screws to the iliac bone. A poly-ethylene cup was finally cemented into the metal cage. Deambulation was allowed one week after surgery, but weightbearing was delayed two months. Clinical evaluation was determined using Harris hip score (HHS). The stability of the acetabular implant was assessed according to Gill criteria. The progression of the bone graft was evaluated using Gross grading. Results: 2 patients developed deep infection that was treated by
There are few reports of the surgical treatment for late stage Freiburg’s disease with flattening of the metatarsal head and osteoarthritis. We describe the results of the surgical treatment of ten consecutive patients with advanced stage Freiburg’s disease (Smillie’s stage V), using a technique that has not been published previously.
