Introduction. The management of periprosthetic pelvic bone loss is a challenging problem in hip revision surgery. This study evaluates the minimum 10-year clinical and radiographic outcome of major column structural allografts combined with the Burch-Schneider antiprotrusio cage for acetabular reconstruction. Methods. From January 1992 to August 2005, 106 hips with periprosthetic osteolysis underwent acetabular revision using massive allografts and the Burch-Schneider antiprotrusio cage. Forty-five patients (49 hips) died for unrelated causes without further surgery. Fifty-nine hips in 59 patients underwent clinical and radiographic evaluation at an average follow-up of 15.1 years. There were 17 male and 42 female patients, with age ranging from 29 to 83 years (mean 59). Results. Ten hips required rerevision because of infection (3), aseptic loosening (6), and flange breakage (1). Moreover, 4 cages showed x-ray signs of instability with severe bone resorption. The survivorship of the Burch-Schneider cage at 21.9 years with removal for any reason or radiographic migration and aseptic or radiographic failure as the end points were 76.3 and 81.4, respectively. The average Harris hip score improved from 33.2 points preoperatively to 75.7 points at the latest follow-up (p < 0.001). Discussion. In hip revision surgery, severe deficiency of pelvic bone stock is a critical concern because of the difficulty in providing a stable and durable fixation of the prosthesis. Although antiprotrusio cages have a limited role in acetabular revision, the use in association with massive allografts in extended bone loss demonstrated highly successful long-term results, enabling bone stock restoration and cup stability.

Revision after failed femoral components may be technically demanding due to loss of peri-prosthetic bone. This retrospective study evaluated the long-term results of femoral revision using the cementless Wagner Self-Locking stem. Between 1992 and 1998, 68 consecutive hips in 66 patients underwent femoral revision using this implant. A total of 25 patients died from unrelated causes without further revision; the remaining 41 hips in 41 patients (12 men and 29 women) with a mean age of 61 years (29 to 80) were reviewed at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral approach was used in 32 hips. A total of five stems required further revision because of infection in two, progressive subsidence in two and recurrent dislocation in one. Four hips had dislocated and eight stems had subsided ≥ 10 mm. The mean Harris hip score improved from 33 points pre-operatively to 75 points at final follow-up (p < 0.001). In all, 33 stems (91.7%) showed radiological signs of stable bone fixation. The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%) and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship with revision and ≥ 10 mm migration of the stem as the endpoint was 83.6% (95% CI 76.6% to 91.4%).

This study shows quite good survival and moderate clinical outcome when using a monoblock tapered titanium stem for supporting the regeneration of bone in complex revision hip surgery.

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 resection-arthroplasty (2 persistent infections, 2 inadequate bone stock, 1 recurrent infection). In 4 cases the spacer dislocated, being treated by non-surgical reduction. The reimplanted patients (24) showed no clinical or laboratory signs of infection recurrence, with a mean HHS score of 79 (range 53 to 100); no radiographic signs of loosening were observed.

Discussion: the use of a preformed antibiotic-loaded spacer in two-stage revisions, allowing a local antibiotic release together with some degree of joint motion, appears to enhance infection’s treatment improving patients’ quality of life and functional recovery.

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 resection-arthroplasty. Aseptic loosening of acetabular cage following an extensive resorption of bone graft was observed in 6 cases and 3 of them underwent rerevision. X-ray signs of graft incorporation occurred in 48 hips. Average HHS values of 30 (range, 11 to 81) and 75 (range, 28 to 100) points were assessed respectively in the preoperative time and at follow-up.

Discussion and Conclusions: In severe acetabular bone deficiencies the application of reinforcement rings in combination with massive allografts has been advocated in order to prevent bone graft resorption and cup loosening. Burch-Schneider Anti-Protrusio Cage is able to protect the graft spanning bone defects and promoting augmentation of periprosthetic bone stock. With an aseptic failure rate of 8.9% and a total survival rate of 85.7% at an average of 11.7 years, the use of APC and structural allograft proved out to be an effective procedure in the long-term reconstructive treatment of extensive loss of acetabular bone stock.

A clinical retrospective study was conducted. Results of isolated decompression for degenerative lumbar stenosis was compared with the outcome in patients who underwent decompression-stabilisation.

From January 1992 to December 2002, 127 patients (average age 65.5) with lumbar degenerative stenosis surgically treated were studied. In all patients the Roy-Camille technique was used for decompression; in 41 patients decompression and posterior stabilisation procedures were carried out. Average follow-up was 6 years (range 2–11 years).

The outcomes, evaluated according to Lassale classification, were satisfactory in 81% of the decompressed group while improved to 88% in the stabilised–decompressed group. Three patients of the first group required stabilisation for intractable low back pain (one patient) and lumboradicular symptoms (two patients), while problems related to the device (one hardware failure) and two instances of adjacent segmental instability were seen in the second group.

Decompression alone is associated with an increased rate of residual low back pain (one patient in this cohort required fusion). The decompression–stabilisation procedure reduces the incidence of low back pain but is associated with other complications such as significant blood loss, possible wound infections, urinary tract infections (due to increased surgical time), device failures, root impingement and late adjacent segmental pathologies.

The Roy Camille technique is effective for achieving adequate decompression. The surgeon should always be aware of patients who might require fusion. The instrumented stabilisation should be reserved for patients with chronic low back pain and evident instability, degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis.