Total hip arthroplasty (THA) in patients under 30 years remains a challenge. The long-term survival data are often disappointing. In our institution, we have always used cemented components in all patients under 30 years, combined with acetabular impaction bone grafting (IBG), if necessary.

We reviewed 139 consecutive patients (180 hips) treated between 1986 to 2014. Mean age at time of surgery was 24 (13–30.0) years. Acetabular IBG was applied in 127 (71%) cases. AAOS cavitary defect was seen in 26 (14%) cases, a AAOS segmental defect in 51 (28%) and a combination in 17 (9%).

The mean preoperative HHS improved from 47 (20–81) to 87 (28–100) at review. During follow-up 26 hips have been revised (23 cups and 11 stems). Indications for revision were aseptic loosening (n=15), septic loosening (n=5), recurrent dislocation (n=3), wear (n=1), and stem fracture (n=1).

The 10-year Kaplan-Meier survival of any component with endpoint revision for any reason was 87% (95% CI 79%–92%) and for aseptic loosening 92% (84%–96%). The 15-year survival of any component with revision for any reason as the endpoint was 77% (65%–86%) and for aseptic loosening 84% (71%–92%).

Cemented THA and, if needed with impaction bone grafting, in patients under 30 years provides satisfying long-term results up to 15 years after surgery. Probably this biological approach with IBG may facilitate the inevitable revisions in the future in these young patients because of more bone stock.

Introduction

The different types of treatment for osteonecrosis of the femoral head have not led to a consensus about which treatment is best for the different stages. Particularly in the later stages of osteonecrosis, the disease still progresses to destruction of the femoral dome. The purpose of our study was to check the outcome of bone impaction grafting used for the head-preserving treatment of severe femoral head osteonecrosis. In order to preserve the femoral head, the sphericity and mechanical properties of the femoral dome must be contained and further collapse prevented.

Introduction: Loosening of acetabular components often lead to excessive bone defects. Managing severe acetabular bone loss in revision arthroplasty is a serious or sometimes even an impossible challenge. Several authors even have published disappointing results. The purpose of this study was to evaluate the long term clinical and radiographic results of acetabular reconstruction with the use of bone impaction grafting and a cemented cup in cases with very large acetabular defects.

Methods: In this historical prospective study, 27 hips (25 patients) with large acetabular defects (AAOS type III and IV, Paprosky type 2B to 3B) were reviewed. In all cases an extensive reconstruction with the use of bone impaction grafting and a large rim wire mesh (Stryker Howmedica, Newbury, UK) was performed. All patients have had a six week bed rest period or 3 weeks of bed rest with 3 weeks of non-weight bearing mobilization. No patient was lost to follow-up. Three patients died during follow-up, the cause of death was in all cases not related to the surgery. All medical files and radiographs were analyzed.

Results: After a mean follow-up of 8.8 years (range 4 to 14.1), 3 hips needed repeat revision and another 2 hips were considered radiographic loose. Reasons for repeat revision were: septic loosening after 4.7 years, aseptic/traumatic loosening after 5.8 years and a broken-out reconstruction after 5 weeks because lack of compliance of the patient.

Kaplan-Meier analysis showed a ten-year survival rate of 87% (95%C.I. 73.1–100%) with end point acetabular revision for any reason and 95% (95%C.I. 86.2–100%) with end point acetabular revision because of aseptic loosening. The mean preoperative HHS was 55 points and improved to 72 points postoperative.

Conclusion: Acetabular reconstruction using impaction bone grafting and a cemented cup can produce favorable long-term results in patients with massive acetabular bone-stock defects. It is the only revision technique which restores massive acetabular bone stock loss. However, in these extensive defects it is a technical demanding procedure and should only be used by surgeons with extensive experience with this technique.

Introduction: Results of primary total hip arthoplasty (THA) for osteonecrosis of the femoral head are improving with newer cementation techniques and components. However not much is known about results of THA after an initial femoral head preserving procedure. The purpose of this study is to compare the complications and the clinical and radiological outcome of THA after failed transtrochanteric rotational osteotomy (Sugioka technique) (THA after TRO) and THA after failed bone impaction grafting (THA after BIG) for osteonecrosis of the femoral head.

Methods: In this retrospective comparative study, sixteen cemented THA after TRO and seventeen cemented THA after BIG were performed from 1994 to 2004. These groups were compared at a minimum follow-up time of two years. The average age at time of THA was 35 years in the THA after TRO group and 39 in the THA after BIG group.

Results: In THA after TRO, perioperative blood loss was significantly increased, operation time was significantly longer, and hospital admission was significantly longer compared with THA after BIG. In THA after TRO, 4 patients required re-operations because of infection (2) and dislocations (2) compared to one re-operation in THA after BIG (revision of acetabular cup). A radiolucency of the cup without re-operation was observed in one patient in the THA after TRO group. The average Harris Hip Score (HHS) in THA after TRO improved from 52 points prior to THA to 89 points at time of review and in the THA after BIG group from 42 to 91 points with a higher rise of HHS per year of follow-up.

Discussion: We conclude that a THA after TRO was technically more demanding with a higher rate of complications and re-operations compared to THA after BIG. However, because of the small groups, no significant difference in outcome was demonstrated.

Introduction: Osteonecrosis of the distal femur produces a segment of dead bone in the weight-bearing portion of the femoral condyle, frequently associated with subchondral fracture and collapse, and eventually resulting in secondary osteoarthritis.

Materials and Methods: We developed a new surgical technique; the osteonecrotic lesion was removed and impacted bone grafts were used to regain sphericity and prevent collapse. In this prospective one surgeon study, we included 9 consecutive knees (6 patients) with extensive steroid-associated osteonecrotic lesions of the femoral condyles. A new staging system was developed that includes location and quantification of the osteonecrotic lesion.

Results: Six knees showed a preoperative collapse. The mean age of the patients was 31 years (range, 16–47 years). At a mean follow up of 51 months (range, 29–93 months), no conversion to total knee arthroplasty was performed. The objective Knee Society Score improved from 63 to 89 points. The functional Knee Society Score improved from 19 to 81 points. At follow up, there was no progression of collapse observed and only 3 knees showed slight signs of osteoarthritis. The clinical success rate was 75%, and 78% were radiologically successful.

Discussion: This method is attractive as a salvage procedure, is relatively simple and quick and does not interfere with an eventual future total knee arthroplasty.

Introduction: The transtrochanteric rotational osteotomy according to Sugioka is used to preserve the femoral head and to prevent secondary osteoarthritis in young patients with osteonecrosis of the femoral head. Several Japanese studies showed favorable results, but European and American studies were disappointing. However, many factors could be responsible for this outcome including race dependent differences and the followed post-operative rehabilitation program. The purpose of our study was to investigate this transtrochanteric rotational osteotomy in Caucasian patients with osteonecrosis in which we followed the original method of Sugioka as close as possible including a 6 months period of non-weightbearing.

Methods: In a single surgeon prospective study we included 26 hips in 22 consecutive patients who were followed for 8.7 years (range, 6.6–10 years) after surgery. The average age at time of surgery was thirty-two years (range, 22–49 years). No patient was lost to follow up. According the ARCO classification, 7 hips were in stage 2, 2 hips in stage 3 early and 17 hips in stage 3 late.

Results: At review 17 hips had been converted to total hip arthroplasty; 2 for infection, 3 for failed osteosyntheses or non-healing of the osteotomy, 12 for progressive osteoarthritis. Taking conversion to total hip arthroplasty for any reason or Harris Hip Score below 70 as endpoint, the clinical survival rate using the Kaplan-Meier analysis was 56 per cent after 7 years (95% C.I. 36–76%). Patients with a higher age at time of surgery had a tendency to a lower clinical survival rate. Taking conversion to total hip arthroplasty, progression of collapse of the femoral head or progression of osteoarthritis of the femoral head as endpoint, the radiological survival rate using the Kaplan-Meier analysis was 89 per cent after 1 year (95% C.I. 68–100%) for patients without pre-operative collapse of the femoral head. For patients with a pre-operative collapse of the femoral head, this survival rate was 35 per cent after 1 year (95% C.I. 13–58%).

Conclusion: Even after excluding the failures due to problems with osteosynthesis the results were not satisfying and the osteoarthritic process was not delayed in an effective way. Based on our results we cannot recommend this technique as an alternative for total hip arthroplasty in Caucasians.

Introduction: The purpose of this study was to evaluate the long-term clinical and radiological outcome of instrumented femoral revisions after failed total hip arthroplasties using the impaction bone grafting technique with morsellized bone chips in combination with a cemented polished stem.

Methods: Thirty-three consecutive femoral reconstructions were performed between November 1991 and February 1996 using the X-Change femoral impaction system with fresh frozen morsellized bone grafts and a cemented polished Exeter stem. All patients were prospectively followed. The learning curve with this new technique is included in this report. This technique was used in twenty-four women and nine men; the average age at surgery was sixty-three years (range 33–82). Femoral bone stock defects were classified according to the Endoklinik classification as grade 1 in three hips, grade 2 in fourteen hips, grade 3 in twelve hips and grade 4 in four hips. At a minimal eight years follow-up no patient was lost to follow-up, but eight patients died (at 0.5, 3.5, 3.5, 7.0, 7.0, 7.5 and 9.0 after reconstruction). All were followed until death, none of these deaths was related to the surgery, and none had a re-revision

Results: No femoral reconstruction was re-rerevised at a mean follow-up of 10.4 years (range 8 to 13 years). However, there were three femoral fractures during follow-up (at 3, 6 and 22 months), all at the level of tip of the prostheses. All healed after plating, all femoral implants were left in situ. The average Harris hip score improved from 49 prior to surgery to 85 at review (68–100). The average migration of the stem within the cement mantle was three mm (0–14 mm), most migration was seen in the first year. Radiologically, there were no failures. With an endpoint of femoral revision for any reason, with endpoint aseptic loosening or with endpoint radiological loosening the survival rate using the Kaplan-Meier analysis was hundred per cent in all situations (one-sided 95% C.I. 100–91.3 %)

Conclusions Femoral revision using bone impaction grafting with fresh frozen bone grafts and a cemented polished stem showed an excellent survival at eight to thirteen years follow-up.

Aims: To test the outcome of acetabular revisons with impacted morsellized bone grafts and a cemented cup at a minimum follow-up of 15 years. Methods: Between 1979–1986 62 acetabular revisions (58 patients) were performed with impacted bone grafts and a cemented cup. Two cases (2 hips) were lost to FU. The average age at operation was 59.1 years. The indication was aseptic in 56 and septic loosening in 4 hips. Defects were AAOS-classiþed as ñcavitaryñ in 37 and ñcombinedñ 23 cases. Femoral-head allografts were used. Acetabular re-revisions were determined, the HHS obtained and radiographs analyzed. Results: Nineteen cases (20 hips) died within þfteen years after the operation, none had a re-revision. Eleven acetabular re-revisions were performed: 2 septic loosenings (3 and 6 years p.o.), 7 aseptic loosenings (6, 9, 11, 12, 13, 14, 14 year p.o.) and two for cup wear (12 and 17 yrs p.o.). The average HHS at follow-up was 86 (50–100). There were no additional radiographic failures. Using Kaplan-Meier analysis the survival with endpoint revision for any reason was 79% at 15 years and 71% at 20 years; for aseptic loosening of the cup 84% at 15 years and 84% at 20 years. Conclusions: This technique is attractive to reconstruct acetabular bone stock loss.

Introduction: Even in extensive osteonecrosis of the femoral head, a head-preserving method is preferable in younger patients. This study presents the results of bone impaction grafting for osteonecrosis of the femoral head.

Materials and Methods: After a core biopsy and removal of the osteonecrotic area, impacted morsellized bone allografts were used to fill the femoral head to regain sphericity, and to prevent collapse. This prospective, single-surgeon study included 28 consecutive hips in 27 patients with extensive osteonecrotic lesions (ARCO classification Stage 2 (11 hips), Stage 3 (14 hips), and Stage 4 (three hips). Fourteen hips had preoperative collapse. The mean age of the patients was 33 years (range, 15–55 years).

Results: At a mean follow-up of 42 months (range, 24–119 months), eight hips (29%) had been converted to a total hip arthroplasty. Of the 20 reconstructions that were in situ, 18 were clinically successful (90%) and 70% were radiologically successful. Patients who were younger than 30 years at surgery had a significantly better radiologic outcome, even when compared to heads with higher stages of osteonecrosis. Patients with preoperative collapse or a continuous use of corticosteroids had disappointing results.

Discussion: This method is attractive as a salvage procedure for osteonecrosis of the femoral head. It is relatively simple and quick to perform, and it does not intervene with an eventual future hip arthroplasty.

Introduction: Between 1985 and 1995 an uncemented Osteonics hip prosthesis with bipolar Universal Head was the implant of choice in young patients with osteonecrosis of the femoral head and with posttraumatic secondary osteoarthritis of the hip.

Materials and Methods: 30 bipolar hemiarthroplasties were performed in 24 patients with an average age of 34 years. Twenty-six hips had osteonecrosis of the femoral head and 4 hips had secondary osteoarthritis. All prostheses were Osteonics Omnifit collarless stems with an UHR universal head. 11 were non-HA-coated prostheses (NG) and 19 proximal HA-coated prostheses (HA). The mean duration of follow-up was 10.4 years.

Results: Clinically, at final follow-up, the Harris Hip Score increased from a preoperative average of 41 points to 76 points (NG 70 and HA 80 points). Thigh or groin pain was present in 16 of 30 hips (NG 3/11 and HA 10/19). Radiographically, a subsidence of 5 mm or more was the major problem in the non-coated prostheses, 11 of 30 hips (NG 10/11, HA 1/19), but osteolysis was mainly seen in the HA-coated group, 20 of 30 hips (HA 17/19, NG 3/11). Total proximal migration of 5 mm or more of the bipolar head was found in 18 prostheses (NG 5/11 and HA 13/19). The revision rate for aseptic loosening was 8 of the 30 hips (NG 3/11 and HA 5/19). During the revisions, major destruction of the polyethylene (PE) inserts were found.

Discussion: The revision rate of the Osteonics Omnifit Prosthesis with bipolar UHR is too high to use this implant in young patients with ON. Bone destruction due to third body wear is probably the main cause. Extensive proximal femoral bone loss is seen predominately in the HA group. The loosening rate in the HA-coated group showed no difference with the non-coated group although the reason for this is different.