Aims. We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH). Methods. This retrospective comparative study included 81 patients with ONFH; 37 patients (40 hips) underwent CVO with BIG (BIG group) and 44 patients (47 hips) underwent CVO alone (CVO group). Patients in the BIG group were followed-up for a mean of 12.2 years (10.0 to 16.5). Patients in the CVO group were followed-up for a mean of 14.5 years (10.0 to 21.0). Assessment parameters included the Harris Hip Score (HHS), Oxford Hip Score (OHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), complication rates, and survival rates, with conversion to total hip arthroplasty (THA) and radiological failure as the endpoints. Results. There were no significant differences in preoperative and postoperative HHS or postoperative OHS and JHEQ between the BIG group and the CVO group. Complication rates were comparable between groups. Ten-year survival rates with conversion to THA and radiological failure as the endpoints were not significantly different between groups. Successful CVO (postoperative coverage ratio of more than one-third) exhibited better ten-year survival rates with radiological failure as the endpoint in the BIG group (91.4%) than in the CVO group (77.7%), but this difference was not significant (p = 0.079). Conclusion. Long-term outcomes of CVO with BIG were favourable when proper patient selection and accurate surgery are performed. However, this study did not show improvements in treatment results with the concomitant use of BIG. Cite this article: Bone Joint J 2021;103-B(4):665–671

Aims

Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone.

Aims. This single-centre observational study aimed to describe the results of extensive bone impaction grafting of the whole acetabular cavity in combination with an uncemented component in acetabular revisions performed in a standardized manner since 1993. Methods. Between 1993 and 2013, 370 patients with a median age of 72 years (interquartile range (IQR) 63 to 79 years) underwent acetabular revision surgery. Of these, 229 were more than ten years following surgery and 137 were more than 15 years. All revisions were performed with extensive use of morcellized allograft firmly impacted into the entire acetabular cavity, followed by insertion of an uncemented component with supplementary screw fixation. All types of reoperation were captured using review of radiographs and medical charts, combined with data from the local surgical register and the Swedish Hip Arthroplasty Register. Results. Among patients with possible follow-up of ten and 15 years, 152 and 72 patients remained alive without revision of the acetabular component. The number of deaths was 61 and 50, respectively. Of those who died, six patients in each group had a reoperation performed before death. The number of patients with a reoperation was 22 for those with ten-year follow-up and 21 for those with 15 years of follow-up. The Kaplan-Meier implant survival rate for aseptic loosening among all 370 patients in the cohort was 96.3% (95% confidence interval (CI) 94.1 to 98.5) after ten years and 92.8% (95% CI 89.2 to 96.6) after 15 years. Conclusion. Extensive bone impaction grafting combined with uncemented revision components appears to be a reliable method with favourable long-term survival. This technique offers the advantage of bone stock restoration and disputes the long-standing perception that uncemented components require > 50% of host bone contact for successful implant survival. Cite this article: Bone Joint J 2020;102-B(2):198–204

Aims

We previously reported the long-term results of the cementless Duraloc-Profile total hip arthroplasty (THA) system in a 12- to 15-year follow-up study. In this paper, we provide an update on the clinical and radiological results of a previously reported cohort of patients at 23 to 26 years´ follow-up.

Aims. The aim of this study was to compare the incidence of aseptic loosening after the use of a cemented acetabular component and a Trabecular Metal (TM) acetabular component (Zimmer Inc., Warsaw, Indiana) at acetabular revision with bone impaction grafting. Patients and Methods. A total of 42 patients were included in the study. Patients were randomised to receive an all- polyethylene cemented acetabular component (n = 19) or a TM component (n = 23). Radiostereometric analysis and conventional radiographic examinations were performed regularly up to two years post-operatively or until further revision. Results. The proximal migration was significantly higher in the cemented group. At two years, the median proximal migration was 1.45 mm and 0.25 mm in the cemented and TM groups, respectively (p = 0.02). One cemented component was revised due to dislocation. There were no revisions in the TM group. Conclusion. Lower proximal migration in the TM group suggests that this design might be associated with a lower risk of aseptic loosening in the long term compared with an all polyethylene cemented component. Longer follow-up is required to confirm the clinical advantages of using this component at acetabular revision. Cite this article: Bone Joint J 2017;99-B:880–6

We evaluated the accuracy with which a custom-made acetabular component could be positioned at revision arthroplasty of the hip in patients with a Paprosky type 3 acetabular defect.

A total of 16 patients with a Paprosky type 3 defect underwent revision surgery using a custom-made trabecular titanium implant. There were four men and 12 women with a median age of 67 years (48 to 79). The planned inclination (INCL), anteversion (AV), rotation and centre of rotation (COR) of the implant were compared with the post-operative position using CT scans.

A total of seven implants were malpositioned in one or more parameters: one with respect to INCL, three with respect to AV, four with respect to rotation and five with respect to the COR.

To the best of our knowledge, this is the first study in which CT data acquired for the pre-operative planning of a custom-made revision acetabular implant have been compared with CT data on the post-operative position. The results are encouraging.

Cite this article: Bone Joint J 2015; 97-B:780–5.

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: Bone Joint J 2014;96-B:1478–84.

In developmental dysplasia of the hip (DDH), a bone defect is often observed superior to the acetabulum after the reconstruction at the level of the true acetabulum during total hip replacement (THR). However, the essential amount of uncemented acetabular component coverage required for a satisfactory outcome remains controversial. The purpose of this study was to assess the stability and function of acetabular components with a lack of coverage > 30% (31% to 50%). A total of 760 DDH patients underwent THR with acetabular reconstruction at the level of the true floor. Lack of coverage above the acetabular component of > 30% occurred in 56 patients. Intra-operatively, autogenous morcellised bone grafts were used to fill the uncovered portion. Other than two screws inserted through the acetabular shell, no additional structural supports were used in these hips. In all, four patients were lost to follow-up. Therefore, 52 patients (52 hips, 41 women and 11 men) with a mean age of 60.1 years (42 to 78) were available for this study at a mean of 4.8 years (3 to 7). There were no instances of prosthesis revision or marked loosening during the follow-up. The Harris hip score improved from a mean of 40.7 points (sd 12.2) pre-operatively to 91.1 (sd 5.0) at the last follow-up. Radiological analysis with medical imaging software allowed us to calculate the extent of the uncoverage in terms of the uncovered arc of the implant as viewed on the anteroposterior pelvic radiograph. From this we propose that up to 17 mm of lateral undercoverage in the presence of a stable initial implantation in the presence of bone autografting, with an inclination angle of the acetabular component between 40° and 55°, is acceptable. This represents undercoverage of ≤ 50%.

Cite this article: Bone Joint J 2013;95-B:1178–83.

The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising.

Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.

We evaluated the outcome of 104 consecutive primary cemented Exeter femoral components in 78 patients (34 men, 44 women) under the age of 40 years who underwent total hip replacement between October 1993 and May 2004. The mean age at operation was 31 years (16 to 39). No hip was lost to follow-up, but three patients (four hips) died. None of the deaths were related to the surgery. At a mean follow-up of 6.2 years (2 to 13), three femoral components had been revised for septic loosening. Using Kaplan-Meier survival analysis, the seven-year survival of the component with revision for any reason as the endpoint was 95.8% (95% confidence interval 86.67 to 98.7). The seven-year survival with aseptic femoral loosening as the endpoint was 100% (95% confidence interval 100).

The cemented Exeter femoral component in patients under the age of 40 shows promising medium-term results. As it is available in a wide range of sizes and offsets, we could address all types of anatomical variation in this series without the need for custom-made components.

Allografts of bone from the femoral head are often used in orthopaedic procedures. Although the donated heads are thoroughly tested microscopically before release by the bone bank, some surgeons take additional cultures in the operating theatre before implantation. There is no consensus about the need to take these cultures. We retrospectively assessed the clinical significance of the implantation of positive-cultured bone allografts. The contamination rate at retrieval of the allografts was 6.4% in our bone bank. Intra-operative cultures were taken from 426 femoral head allografts before implantation; 48 (11.3%) had a positive culture. The most frequently encountered micro-organism was coagulase-negative staphylococcus. Deep infection occurred in two of the 48 patients (4.2%). In only one was it likely that the same micro-organism caused the contamination and the subsequent infection.

In our study, the rate of infection in patients receiving positive-cultured allografts at implantation was not higher than the overall rate of infection in allograft surgery suggesting that the positive cultures at implantation probably represent contamination and that the taking of additional cultures is not useful.

This retrospective study describes the long-term results of core decompression and placement of a non-vascularised bone graft in the management of avascular necrosis of the femoral head. We treated 80 hips in 65 patients, 18 by a cortical tibial autograft and 62 by a fibular allograft. The mean age of the patients was 36 years (sd 13.2). A total of 78 hips were available for evaluation of which pre-operatively six were Ficat-Arlet stage 0, three stage I, 31 stage IIA, 16 stage IIB, 13 stage III and nine stage IV.

A total of 34 hips (44%) were revised at a mean of four years (sd 3.8). Survivorship analysis using a clinical end-point showed a survival rate of 59% five years after surgery. We found a significant difference (p = 0.002) in survivorship, when using a clinical and radiological end-point, between the two grafts, in favour of the tibial autograft. We considered this difference to be the result of the better quality and increased volume of tibial bone compared with that from the trochanteric region used with the fibular allograft.

This is a relatively simple, extra-articular and reproducible procedure. In our view core decompression, removal of the necrotic tissue and packing of the cancellous grafts into the core track are vital parts of the procedure.