Revision total hip arthroplasty (THA) is a challenging scenario following complex primary THA for developmental dysplasia of hip (DDH). Our study envisages the long-term outcomes of revision DDH and the role of lateral structural support in socket fixation in these young patients who may require multiple revisions in their life-time.

Hundred and eighteen consecutive cemented revision THAs with minimum follow up of 5 years following primary diagnosis of DDH operated between January 1974 and December 2012 were analysed for their clinical and radiological outcomes.

The mean follow-up of 118 patients was 11.0 years (5.1–39.6 years). The Kaplan Mier survivorship at 11 years with end point as revision for any reason was 89.8% (CI 81.1–98.4). Of 118 revisions, 88 acetabular revisions were for aseptic loosening. Out of the acetabular revisions, 21 had pre-existing structural bone grafts from primary surgery, of which only 3 needed structural re-grafting during revision. Amongst the remaining 18 hips, the lateral support from the previous graft facilitated revision with no requirement of additional structural graft. Sixty-three hips did not have any form of grafting during primary operation. Amongst them, 35 had bone grafting in revision surgery (18 structural grafting).

This study reports the largest number of revision THAs with primary diagnosis of DDH with the longest follow up. In our experience, the lateral support from the structural graft done in primary operation appears to have provided benefit in subsequent revision socket fixation.

The choice of stem length in total hip revision with impaction bone grafting of femur is essentially based upon the grade of cavitation of femur and surgeon's preference. The standard length stem has been often critiqued for the apprehension of peri-prosthetic fracture. Our study highlights the importance of proximal bone stock rather than distal cavitation in determining the length of femoral stem.

168 total hip revisions of 162 patients with impaction bone grafting and cemented standard C-stem (done with standardized technique) between 1995 and 2008 at a tertiary referral centre were included. Revisions for infection and segmental bone defects were excluded. Serial radiographs were retrospectively analysed by two people independently, using Endoklinik classification, Gruen zones and more and outcomes were analysed.

Mean follow-up of the 168 revision hips was 10.5 years (range 5 – 19.1 years). 14 patients (8.3%) were re-revised, reasons being, persistent deep infection (1.8%), repeated dislocations (1.2%), cup loosening (4.8%) and stem loosening (1.2%). Only 1 patient (0.6%) was re-revised due to stem loosening alone. No peri-prosthetic fractures or stem breakage were identified.

Use of standard stem length in hip revisions with impaction bone grafting doesn't increase the risk of peri-prosthetic fractures even during long term follow up period. This questions the principle of bypassing the distal cavitation of femur by 2 cortical diameters with the use of long stem. In our experience, a good proximal femur support aids in the performance of standard length cemented stems in revision for aseptic loosening irrespective of grade of distal cavitation for cavitory defects of femur treated with impaction bone grafting.

Structural bulk autografts restore the severe bone loss at primary hip arthroplasty in dysplastic hips and have shown to have good long term outcomes. There are only a few reports of revision arthroplasty for these sockets that fail eventually. We report on a series of such primary hips which underwent cemented revision of the socket for aseptic loosening and their outcomes.

A retrospective review was performed from our database to identify fifteen acetabular revisions after previous bulk autograft. The mean age at revision was 53.9 years (range 31–72.1). The mean duration between the primary and revision arthroplasty was 12.4 years (range 6.6 – 20.3). All procedures were done using trochanteric osteotomy and three hips also needed the femoral component revision. All fifteen hips needed re-bone grafting at the revision surgery to restore the new socket to the level of the true acetabulum. Of these ten hips had morsellised impaction allograft, and the remaining five also needing a structural bulk allograft.

Two sockets underwent re-revision at mean 7.5 years for aseptic loosening. One patient had a dislocation that was reduced closed. At a mean follow up of 5.7 years, one socket showed superior migration, but was stable and did not need further intervention. Two other sockets also showed radiological evidence of loosening, and are being closely monitored.

The medium term results of cemented acetabular revision in this younger age group are satisfactory, with repeat bone grafting being required to restore the true acetabular position. Though the primary arthroplasty with bulk bone graft recreates the acetabular bone stock, significant bone loss due to the mechanical loosening of the socket needs to be anticipated in revision surgery.

Introduction

We present the outcome of 297 acetabular revisions using bone grafting and cemented acetabular components in 297 patients, with a mean follow-up of 8 years 3 months (5–20 years).

The C-Stem in its design as a triple tapered stem, is the logical development of the original Charnley flat-back polished stem. The concept, design and the surgical technique cater for a limited slip of the stem within the cement mantle transferring the load more proximally.

Five thousand two hundred and thirty three primary procedures using a C-stem have been carried out since 1993. We reviewed all 621 cases that had their total hip arthroplasty before 1998.

Sixty nine patients (70 hips) had died and 101 hips had not reached a ten-year clinical and radiological follow-up and had not been revised. Thirty-two hips had been revised before 10 years, none were revised for aseptic stem loosening and no stems. The indications for revision were Infection in 4, dislocation in 3, aseptic cup loosening in 24 and unexplained pain in 1.

The remaining 418 hips had a mean follow-up of 12 years (range 10–15 years). There were 216 women and 173 men, and 34 patients had bilateral LFAs. The patients' mean age at surgery was 53 years (range 16–83 years). Thirty four hips had been revised at the time of review. The reasons for revision were infection in 5, dislocation in 2, aseptic cup loosening in 24 and 1 for neuralgia paraesthetica where the stem was well fixed. Two hips were revised for stem fracture.

There were no revisions for stem loosening but 2 stems were revised for fracture - both with a defective cement mantle proximally. The clinical results are very encouraging and they support the concept of the Charnley cemented low friction arthroplasty, but place a demand on the understanding of the technique and its execution at surgery.

Introduction

The aim of the study was to whether the bone grafting techniques used affected the long term stability of the acetabular implant.