Aims. The management of acetabular defects at the time of revision hip arthroplasty surgery is a challenge. This study presents the results of a long-term follow-up study of the use of irradiated allograft bone in acetabular reconstruction. Patients and Methods. Between 1990 and 2000, 123 hips in 110 patients underwent acetabular reconstruction for aseptic loosening, using impaction bone grafting with frozen, irradiated, and morsellized femoral heads and a cemented acetabular component. A total of 55 men and 55 women with a mean age of 64.3 years (26 to 97) at the time of revision surgery are included in this study. Results. At a mean follow-up of 16.9 years, there had been 23 revisions (18.7%), including ten for infection, eight for aseptic loosening, and three for dislocation. Of the 66 surviving hips (58 patients) that could be reassessed, 50 hips (42 patients; 75.6%) were still functioning satisfactorily. Union of the graft had occurred in all hips with a surviving implant. Survival analysis for all indications was 80.6% at 15 years (55 patients at risk, 95% confidence interval (CI) 71.1 to 87.2) and 73.7% at 20 years (eight patients at risk, 95% CI 61.6 to 82.5). Conclusion. Acetabular reconstruction using frozen, irradiated, and morsellized allograft bone and a cemented acetabular component is an effective method of treatment. It gives satisfactory long-term results and is comparable to other types of reconstruction. Cite this article: Bone Joint J 2018;100-B:1449–54

Previously, radiostereometric analysis following hip revision performed using impacted morsellised allograft bone and a cemented Exeter stem has shown continuous subsidence of the stem for up to five years. It is not known whether the subsidence continues thereafter. In our study, 17 of 25 consecutive osteo-arthritic patients with aseptically loose stems who underwent first-time revision using impacted morsellised allograft bone and a cemented Exeter stem were followed by yearly radiostereometric examinations for nine years. The mean subsidence at six weeks was 1.1 mm (0.1 to 2.3), from six weeks to one year 1.3 mm (0 to 2.6), from one to five years 0.7 mm (0 to 2.0), and from five to nine years 0.7 mm (0.1 to 3.1). That from six weeks to nine years was 2.7 mm (0 to 6.4) (95% confidence interval 2.0 to 3.5). The Charnley pain score significantly improved after revision, and was maintained at nine years, but walking ability deteriorated slightly as follow-up extended. Of the eight patients who were not followed for nine years, two had early subsidence exceeding 11 mm. Our findings show that in osteo-arthritic patients who undergo revision for aseptic loosening of the stem using impacted morsellised allograft bone and a cemented Exeter stem, migration of the stem continues over nine years at a slower rate after the first year, but without clinical deterioration or radiological loosening

A two-stage procedure was carried out on 57 patients with confirmed infection in a hip replacement. Allograft bone was used in the second stage. Pathogenic organisms were identified in all patients. In stage 1, the prosthesis was removed together with infected tissue. Antibiotics were added to customised cement beads. Systemic antibiotics were not used. At the second stage, 45 of the patients had either acetabular impaction grafting, femoral impaction grafting or a combination; 12 had a massive allograft. Eight patients suffered recurrent infection (14%), in six with the original infecting organism. The risk factors for re-infection were multiple previous procedures and highly resistant organisms. We believe that systemic antibiotic therapy should be considered for these patients. Allograft bone is shown to be a useful adjunct in most infected hip replacements with considerable loss of bone stock

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection

We report the results of the revision of 123 acetabular components for aseptic loosening treated by impaction bone grafting using frozen, morsellised, irradiated femoral heads and cemented sockets. This is the first large series using this technique to be reported. A survivorship of 88% with revision as the end-point after a mean of five years is comparable with that of other series.

Aims

The aim of this study was to examine the implant accuracy of custom-made partial pelvis replacements (PPRs) in revision total hip arthroplasty (rTHA). Custom-made implants offer an option to achieve a reconstruction in cases with severe acetabular bone loss. By analyzing implant deviation in CT and radiograph imaging and correlating early clinical complications, we aimed to optimize the usage of custom-made implants.

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection

Aims

Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed.

We retrospectively reviewed 44 consecutive patients (50 hips) who underwent acetabular re-revision after a failed previous revision that had been performed using structural or morcellised allograft bone, with a cage or ring for uncontained defects. Of the 50 previous revisions, 41 cages and nine rings were used with allografts for 14 minor-column and 36 major-column defects. We routinely assessed the size of the acetabular bone defect at the time of revision and re-revision surgery. This allowed us to assess whether host bone stock was restored. We also assessed the outcome of re-revision surgery in these circumstances by means of radiological characteristics, rates of failure and modes of failure. We subsequently investigated the factors that may affect the potential for the restoration of bone stock and the durability of the re-revision reconstruction using multivariate analysis. At the time of re-revision, there were ten host acetabula with no significant defects, 14 with contained defects, nine with minor-column, seven with major-column defects and ten with pelvic discontinuity. When bone defects at re-revision were compared with those at the previous revision, there was restoration of bone stock in 31 hips, deterioration of bone stock in nine and remained unchanged in ten. This was a significant improvement (p <  0.001). Morselised allografting at the index revision was not associated with the restoration of bone stock. . In 17 hips (34%), re-revision was possible using a simple acetabular component without allograft, augments, rings or cages. There were 47 patients with a mean follow-up of 70 months (6 to 146) available for survival analysis. Within this group, the successful cases had a minimum follow-up of two years after re-revision. There were 22 clinical or radiological failures (46.7%), 18 of which were due to aseptic loosening. The five and ten year Kaplan–Meier survival rate was 75% (95% CI, 60 to 86) and 56% (95% CI, 40 to 70) respectively with aseptic loosening as the endpoint. The rate of aseptic loosening was higher for hips with pelvic discontinuity (p = 0.049) and less when the allograft had been in place for longer periods (p = 0.040). . The use of a cage or ring over structural allograft bone for massive uncontained defects in acetabular revision can restore host bone stock and facilitate subsequent re-revision surgery to a certain extent. Cite this article: Bone Joint J 2014;96-B:319–24

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.

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998. The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification. The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively. Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97)

An uncemented hemispherical acetabular component is the mainstay of acetabular revision and gives excellent long-term results.

Occasionally, the degree of acetabular bone loss means that a hemispherical component will be unstable when sited in the correct anatomical location or there is minimal bleeding host bone left for biological fixation. On these occasions an alternative method of reconstruction has to be used.

A major column structural allograft has been shown to restore the deficient bone stock to some degree, but it needs to be off-loaded with a reconstruction cage to prevent collapse of the graft. The use of porous metal augments is a promising method of overcoming some of the problems associated with structural allograft. If the defect is large, the augment needs to be protected by a cage to allow ingrowth to occur. Cup-cage reconstruction is an effective method of treating chronic pelvic discontinuity and large contained or uncontained bone defects.

This paper presents the indications, surgical techniques and outcomes of various methods which use acetabular reconstruction cages for revision total hip arthroplasty.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):73–7.

Aims

It may not be possible to undertake revision total hip arthroplasty (THA) in the presence of massive loss of acetabular bone stock using standard cementless hemispherical acetabular components and metal augments, as satisfactory stability cannot always be achieved. We aimed to study the outcome using a reconstruction cage and a porous metal augment in these patients.

To assess the sustainability of our institutional bone bank, we calculated the final product cost of fresh-frozen femoral head allografts and compared these costs with the use of commercial alternatives. Between 2007 and 2010 all quantifiable costs associated with allograft donor screening, harvesting, storage, and administration of femoral head allografts retrieved from patients undergoing elective hip replacement were analysed.

From 290 femoral head allografts harvested and stored as full (complete) head specimens or as two halves, 101 had to be withdrawn. In total, 104 full and 75 half heads were implanted in 152 recipients. The calculated final product costs were €1367 per full head. Compared with the use of commercially available processed allografts, a saving of at least €43 119 was realised over four-years (€10 780 per year) resulting in a cost-effective intervention at our institution. Assuming a price of between €1672 and €2149 per commercially purchased allograft, breakeven analysis revealed that implanting between 34 and 63 allografts per year equated to the total cost of bone banking.

Cite this article: Bone Joint J 2014;96-B:1307–11

The ‘jumbo’ acetabular component is now commonly used in acetabular revision surgery where there is extensive bone loss. It offers high surface contact, permits weight bearing over a large area of the pelvis, the need for bone grafting is reduced and it is usually possible to restore centre of rotation of the hip. Disadvantages of its use include a technique in which bone structure may not be restored, a risk of excessive posterior bone loss during reaming, an obligation to employ screw fixation, limited bone ingrowth with late failure and high hip centre, leading to increased risk of dislocation. Contraindications include unaddressed pelvic dissociation, inability to implant the component with a rim fit, and an inability to achieve screw fixation. Use in acetabulae with < 50% bone stock has also been questioned. Published results have been encouraging in the first decade, with late failures predominantly because of polyethylene wear and aseptic loosening. Dislocation is the most common complication of jumbo acetabular revisions, with an incidence of approximately 10%, and often mandates revision. Based on published results, a hemispherical component with an enhanced porous coating, highly cross-linked polyethylene, and a large femoral head appears to represent the optimum tribology for jumbo acetabular revisions.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):64–7.

This review summarises the technique of impaction grafting with mesh augmentation for the treatment of uncontained acetabular defects in revision hip arthroplasty.

The ideal acetabular revision should restore bone stock, use a small socket in the near-anatomic position, and provide durable fixation. Impaction bone grafting, which has been in use for over 40 years, offers the ability to achieve these goals in uncontained defects. The precepts of modern, revision impaction grafting are that the segmental or cavitary defects must be supported with a mesh; the contained cavity is filled with vigorously impacted morselised fresh-frozen allograft; and finally, acrylic cement is used to stabilise the graft and provide rigid, long-lasting fixation of the revised acetabular component.

Favourable results have been published with this technique. While having its limitations, it is a viable option to address large acetabular defects in revision arthroplasty.

Cite this article: Bone Joint J 2017;99-B(1 Supple A):25–30.

We report the clinical and radiographic outcomes of 208 consecutive femoral revision arthroplasties performed in 202 patients (119 women, 83 men) between March 1991 and December 2007 using the X-change Femoral Revision System, fresh-frozen morcellised allograft and a cemented polished Exeter stem. All patients were followed prospectively. The mean age of the patients at revision was 65 years (30 to 86). At final review in December 2013 a total of 130 patients with 135 reconstructions (64.9%) were alive and had a non re-revised femoral component after a mean follow-up of 10.6 years (4.7 to 20.9). One patient was lost to follow-up at six years, and their data were included up to this point. Re-operation for any reason was performed in 33 hips (15.9%), in 13 of which the femoral component was re-revised (6.3%). The mean pre-operative Harris hip score was 52 (19 to 95) (n = 73) and improved to 80 (22 to 100) (n = 161) by the last follow-up. Kaplan–Meier survival with femoral re-revision for any reason as the endpoint was 94.9% (95% confidence intervals (CI) 90.2 to 97.4) at ten years; with femoral re-revision for aseptic loosening as the endpoint it was 99.4% (95% CI 95.7 to 99.9); with femoral re-operation for any reason as the endpoint it was 84.5% (95% CI 78.3 to 89.1); and with subsidence ≥ 5 mm it was 87.3% (95% CI 80.5 to 91.8). Femoral revision with the use of impaction allograft bone grafting and a cemented polished stem results in a satisfying survival rate at a mean of ten years’ follow-up.

Cite this article: Bone Joint J 2015; 97-B:771–9.

A number of studies have reported satisfactory results from the isolated revision of an acetabular component. However, many of these studies reported only the short- to intermediate-term results of heterogeneous bearing surfaces in a mixed age group.

We present our experience of using a ceramic-on-ceramic (CoC) bearing for isolated revision of an uncemented acetabular component in 166 patients (187 hips) who were under the age of 50 years at the time of revision. There were 78 men and 88 women with a mean age of 47.4 years (28 to 49). The most common reason for revision was polyethylene wear and acetabular osteolysis in 123 hips (66%), followed by aseptic loosening in 49 hips (26%).

We report the clinical and radiological outcome, complication rate, and survivorship of this group. The mean duration of follow-up was 15.6 years (11 to 19).

The mean pre-operative Harris hip score was 33 points (1 to 58), and improved to a mean of 88 points (51 to 100) at follow-up. The mean pre-operative total Western Ontario and McMaster Universities Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8 points (9 to 61) post-operatively. Overall, 153 of 166 patients (92%) were satisfied with their outcome. Kaplan–Meier survivorship analysis, with revision or radiological evidence of implant failure (13 patients, 8%) as end-points, was 92% at 15 years (95% confidence interval 0.89 to 0.97).

Isolated revision of a cementless acetabular component using a CoC bearing gives good results in patients under 50 years of age.

Cite this article: Bone Joint J 2015;97-B:1197–1203.

We retrospectively reviewed 40 hips in 36 patients who had undergone acetabular reconstruction using a titanium Kerboull-type acetabular reinforcement device with bone allografts between May 2001 and April 2006. Impacted bone allografts were used for the management of American Academy of Orthopaedic Surgeons Type II defects in 17 hips, and bulk bone allografts together with impacted allografts were used for the management of Type III defects in 23 hips. A total of five hips showed radiological failure at a mean follow-up of 6.7 years (4.5 to 9.3), two of which were infected. The mean pre-operative Merle d’Aubigné score was 10 (5 to 15) vs 13.6 (9 to 18) at the latest follow-up. The Kaplan-Meier survival rate at ten years, calculated using radiological failure or revision of the acetabular component for any reason as the endpoint, was 87% (95% confidence interval 76.3 to 97.7). A separate experimental analysis of the mechanical properties of the device and the load-displacement properties of bone grafts showed that a structurally hard allograft resected from femoral heads of patients with osteoarthritis should be preferentially used in any type of defect. If impacted bone allografts were used, a bone graft thickness of < 25 mm was acceptable in Type II defects. This clinical study indicates that revision total hip replacement using the Kerboull-type acetabular reinforcement device with bone allografts yielded satisfactory mid-term results

A common situation presenting to the orthopaedic surgeon today is a worn acetabular liner with substantial acetabular and pelvic osteolysis. The surgeon has many options for dealing with osteolytic defects. These include allograft, calcium based substitutes, demineralised bone matrix, or combinations of these options with or without addition of platelet rich plasma. To date there are no clinical studies to determine the efficacy of using bone-stimulating materials in osteolytic defects at the time of revision surgery and there are surprisingly few studies demonstrating the clinical efficacy of these treatment options. Even when radiographs appear to demonstrate incorporation of graft material CT studies have shown that incorporation is incomplete. The surgeon, in choosing a graft material for a surgical procedure must take into account the efficacy, safety, cost and convenience of that material.

Cite this article: Bone Joint J 2014;96-B (11 Suppl A):70–2.

We report the results at a mean of 24.3 years (20 to 32) of 61 previously reported consecutive total hip replacements carried out on 44 patients with severe congenital hip disease, performed with reconstruction of the acetabulum with an impaction grafting technique known as cotyloplasty. The mean age of the patients at operation was 46.7 years (23 to 68) and all were women. The patients were followed post-operatively for a mean of 24.3 years (20 to 32), using the Merle d’Aubigné and Postel scoring system as modified by Charnley, and with serial radiographs. At the time of the latest follow-up, 28 acetabular components had been revised because of aseptic loosening at a mean of 15.9 years (6 to 26), and one at 40 days after surgery because of repeated dislocations. The overall survival rate for aseptic failure of the acetabular component at ten years was 93.1% (95% confidence interval (CI) 86.5 to 96.7) when 53 hips were at risk, and at 23 years was 56.1% (95% CI 49.4 to 62.8), when 22 hips remained at risk. These long-term results are considered satisfactory for the reconstruction of an acetabulum presenting with inadequate bone stock and circumferential segmental defects.

Cite this article: Bone Joint J 2013;95-B:887–92.

Femoral revision after cemented total hip replacement (THR) might include technical difficulties, following essential cement removal, which might lead to further loss of bone and consequently inadequate fixation of the subsequent revision stem.

Femoral impaction allografting has been widely used in revision surgery for the acetabulum, and subsequently for the femur. In combination with a primary cemented stem, impaction grafting allows for femoral bone restoration through incorporation and remodelling of the impacted morsellized bone graft by the host skeleton. Cavitary bone defects affecting meta-physis and diaphysis leading to a wide femoral shaft, are ideal indications for this technique. Cancellous allograft bone chips of 1 mm to 2 mm size are used, and tapered into the canal with rods of increasing diameters. To impact the bone chips into the femoral canal a prosthesis dummy of the same dimensions of the definitive cemented stem is driven into the femur to ensure that the chips are very firmly impacted. Finally, a standard stem is cemented into the neo-medullary canal using bone cement.

To date several studies have shown favourable results with this technique, with some excellent long-term results reported in independent clinical centres worldwide.

Cite this article: Bone Joint J 2013;95-B, Supple A:92–4.

The custom triflange is a patient-specific implant for the treatment of severe bone loss in revision total hip arthroplasty (THA). Through a process of three-dimensional modelling and prototyping, a hydroxyapatite-coated component is created for acetabular reconstruction. There are seven level IV studies describing the clinical results of triflange components. The most common complications include dislocation and infection, although the rates of implant removal are low. Clinical results are promising given the challenging problem. We describe the design, manufacture and implantation process and review the clinical results, contrasting them to other methods of acetabular reconstruction in revision THA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):68–72.

Between 1990 and 2000, 123 hips in 110 patients were reconstructed for aseptic loosening using impaction bone grafting with frozen, irradiated, morsellised femoral heads and cemented acetabular components. This series was reported previously at a mean follow-up of five years. We have extended this follow-up and now describe the outcome of 86 hips in 74 patients at a mean of ten years. There have been 19 revisions, comprising nine for infection, seven for aseptic loosening and three for dislocation. In surviving acetabular reconstructions, union of the graft had occurred in 64 of 67 hips (95.5%).

Survival analysis for all indications at ten years was 83.3% (95% confidence interval (CI) 68 to 89) and 71.3% (95% CI 58 to 84) at 15 years.

Acetabular reconstruction using irradiated allograft and a cemented acetabular component is an effective method of reconstruction, providing results in the medium- to long-term comparable with those of reported series where non-irradiated freshly-frozen bone was used.

The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique.

At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Between 1980 and 2000, 63 support rings were used in the management of acetabular deficiency in a series of 60 patients, with a mean follow-up of 8.75 years (2 months to 23.8 years). There was a minimum five-year follow-up for successful reconstructions. The indication for revision surgery was aseptic loosening in 30 cases and infection in 33. All cases were Paprosky III defects; IIIA in 33 patients (52.4%) and IIIB in 30 (47.6%), including four with pelvic dissociation. A total of 26 patients (43.3%) have died since surgery, and 34 (56.7%) remain under clinical review. With acetabular revision for infection or aseptic loosening as the definition of failure, we report success in 53 (84%) of the reconstructions. A total of 12 failures (19%) required further surgery, four (6.3%) for aseptic loosening of the acetabular construct, six (9.5%) for recurrent infection and two (3.2%) for recurrent dislocation requiring captive components. Complications, seen in 11 patients (18.3%), included six femoral or sciatic neuropraxias which all resolved, one grade III heterotopic ossification, one on-table acetabular revision for instability, and three early post-operative dislocations managed by manipulation under anaesthesia, with no further instability.

We recommend support rings and morcellised bone graft for significant acetabular bone deficiency that cannot be reconstructed using mesh.

Loss of bone stock is a major problem in revision surgery of the hip. Impaction bone grafting of the femur is frequently used when dealing with deficient bone stock. In this retrospective study a consecutive series of 68 patients (69 hips) who had revision of a hip replacement with femoral impaction grafting were reviewed. Irradiated bone allograft was used in all hips. Radiological measurement of subsidence of the stem, incorporation of the graft and remodelling was carried out and showed incorporation of the graft in 26 of 69 hips (38%). However, there was no evidence of trabecular remodelling. Moderate subsidence of 5 mm to 10 mm occurred in ten hips (14.5%), and massive subsidence of > 10 mm in five (7.2%). The results of this study are less favourable than those of others describing studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling noted in other series raises the question as to whether irradiated bone graft may be a significant factor influencing the post-operative outcome

Revision arthroplasty after infection can often be complicated by both extensive bone loss and a relatively high rate of re-infection. Using allograft to address the bone loss in such patients is controversial because of the perceived risk of bacterial infection from the use of avascular graft material. We describe 12 two-stage revisions for infection in which segmental allografts were loaded with antibiotics using iontophoresis, a technique using an electrical potential to drive ionised antibiotics into cortical bone.

Iontophoresis produced high levels of antibiotic in the allograft, which eluted into the surrounding tissues. We postulate that this offers protection from infection in the high-risk peri-operative period. None of the 12 patients who had two-stage revision with iontophoresed allografts had further infection after a mean period of 47 months (14 to 78).

We report the use of porous metal acetabular revision shells in the treatment of contained bone loss. The outcomes of 53 patients with ≤ 50% acetabular bleeding host bone contact were compared with a control group of 49 patients with > 50% to 85% bleeding host bone contact. All patients were treated with the same type of trabecular metal acetabular revision shell. The mean age at revision was 62.4 years (42 to 80) and the mean follow-up of both groups was 72.4 months (60 to 102). Clinical, radiological and functional outcomes were assessed. There were four (7.5%) mechanical failures in the ≤ 50% host bone contact group and no failures in the > 50% host bone contact group (p = 0.068). Out of both groups combined there were four infections (3.9%) and five recurrent dislocations (4.9%) with a stable acetabular component construct that were revised to a constrained liner. Given the complexity of the reconstructive challenge, porous metal revision acetabular shells show acceptable failure rates at five to ten years’ follow-up in the setting of significant contained bone defects. This favourable outcome might be due to the improved initial stability achieved by a high coefficient of friction between the acetabular implant and the host bone, and the high porosity, which affords good bone ingrowth.

The conventional method for reconstructing acetabular bone loss at revision surgery includes using structural bone allograft. The disadvantages of this technique promoted the advent of metallic but biocompatible porous implants to fill bone defects enhancing initial and long-term stability of the acetabular component. This paper presents the indications, surgical technique and the outcome of using porous metal acetabular augments for reconstructing acetabular defects. . Cite this article: Bone Joint J 2013;95-B, Supple A:103–8

Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening. These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment

In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant–bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision.

A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up.

Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail.

Cite this article: Bone Joint J 2013;95-B:777–81.

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.

The purpose of this prospective study was to evaluate the long-term clinical and radiological outcomes of revision of the femoral component of a total hip replacement using impaction bone grafting. Femoral revision with an impacted allograft was performed on 29 patients (31 hips). In all, 21 hips (68%) had grade III or IV femoral defects according to the Endo-Klinik classification. A total of 11 patients (12 hips) died before the ten-year follow-up period. Of the remaining patients, 18 patients (19 hips) were followed for 10 to 15 years; three further patients died during this time. None of the 31 stems underwent further revision of their stem. However, four stems showed extensive subsidence (> 15 mm). One of these patients had a femoral fracture that required fixation. Three other patients had a femoral fracture, two of which required fixation and the other was treated conservatively. Patients with a femoral fracture and/or severe subsidence had significantly more grade IV defects (six of seven hips; p = 0.004). One patient needed a closed reduction for dislocation.

Impaction allografting in revision hip surgery gives good long-term results for femora with grades I, II and III Endo-Klinik-classified defects. Extensive subsidence and femoral fractures were seen mainly in patients with grade IV damaged femora.

The ideal bearing surface for young patients undergoing total hip replacement (THR) remains controversial. We report the five-year results of a randomised controlled trial comparing the clinical and radiological outcomes of 102 THRs in 91 patients who were <  65 years of age. These patients were randomised to receive a cobalt–chrome on ultra-high-molecular-weight polyethylene, cobalt–chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic bearing. In all, 97 hip replacements in 87 patients were available for review at five years. Two hips had been revised, one for infection and one for peri-prosthetic fracture.

At the final follow-up there were no significant differences between the groups for the mean Western Ontario and McMaster Universities osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness, p = 0.99), Short Form-12 (physical component, p = 0.878; mental component, p = 0.818) or Harris hip scores (p = 0.22). Radiological outcomes revealed no significant wear in the ceramic group.

Comparison of standard and highly cross-linked polyethylene, however, revealed an almost threefold difference in the mean annual linear wear rates (0.151 mm/year versus 0.059 mm/year, respectively) (p < 0.001).

The use of allograft struts and cerclage wire, possibly augmented by plate fixation, for the treatment of Vancouver type-B1 peri-prosthetic fractures around a total hip replacement has been strongly advocated. We examined our results using plate fixation without allograft struts and compared them with the results of the use of struts alone or when combined with plate fixation. Of 20 consecutive patients with type-B1 fractures treated by open reduction and plate fixation, 19 were available for follow-up. The fractures healed in 18 patients with a mean time to weight-bearing of ten weeks (4 to 19). There were no cases of infection or malunion. Nonunion occurred in one patient and required a second plate fixation to achieve union.

Safe, cost-effective treatment of Vancouver type-B1 fractures can be performed by plate fixation without the addition of cortical struts. This procedure may allow earlier weight-bearing than allograft strut fixation alone.

We retrospectively evaluated 42 hips which had undergone acetabular reconstruction using the Kerboull acetabular reinforcement device between September 1994 and December 1998. We used autogenous bone chips from the ilium and ceramic particle morsellised grafts, even in large acetabular bone defects, in the early stages of the study. Thereafter, femoral head allograft was used as bulk graft in patients with large acetabular defects. Ceramic blocks and the patients’ contralateral femoral head were also used as bulk graft. The mean follow-up period was 8.7 years (4.3 to 12).

Survivorship analysis was performed using radiological failure of the acetabular component, irrespective of whether it was revised, or not, as the end-point.

The survival rate of the morsellised graft group (25 hips) and the bulk graft group (17 hips) at ten years was 53% (95% confidence interval (CI) 42.5% to 63.5%) and 82% (95% CI 72.4% to 91.6%), respectively. The mid-term results of revision total hip replacement with the Kerboull device were better when bulk graft was used in any size of bone defect.

Failure of total hip arthroplasty with acetabular deficiency occurred in 55 patients (60 hips) and was treated with acetabular revision using morsellised allograft and a cemented metal-backed component. A total of 50 patients (55 hips) were available for clinical and radiological evaluation at a mean follow-up of 5.8 years (3 to 9.5). No hip required further revision of the acetabular component because of aseptic loosening.

All the hips except one had complete incorporation of the allograft demonstrated on the radiographs. A complete radiolucent line of > 1 mm was noted in two hips post-operatively. A good to excellent result occurred in 50 hips (91%). With radiological evidence of aseptic loosening of the acetabular component as the end-point, the survivorship at a mean of 5.8 years after surgery was 96.4%.

The use of impacted allograft chips in combination with a cemented metal-backed acetabular component and screw fixation can achieve good medium-term results in patients with acetabular bone deficiency.

Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores.

Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection

The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening.

These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.

The Vancouver classification has been shown by its developers to be a valid and reliable method for categorising the configuration of periprosthetic proximal femoral fractures and for planning their management. We have re-validated this classification system independently using the radiographs of 30 patients with periprosthetic fractures. These were reviewed by six experienced consultant orthopaedic surgeons, six trainee surgeons and six medical students in order to assess intra- and interobserver reliability and reproducibility. Each observer read the radiographs on two separate occasions. The results were subjected to weighted kappa statistical analysis.

The respective kappa values for interobserver agreement were 0.72 and 0.74 for consultants, 0.68 and 0.70 for trainees on the first and second readings of the radiographs and 0.61 for medical students. The intra-observer agreement for the consultants was 0.64 and 0.67, for the trainees 0.61 and 0.64, and for the medical students 0.59 and 0.60 for the first and second readings, respectively. The validity of the classification was studied by comparing the pre-operative radiological findings within B subgroups with the operative findings. This revealed agreement for 77% of these type-B fractures, with a kappa value of 0.67.

Our data confirm the reliability and reproducibility of this classification system in a European setting and for inexperienced staff. This is a reliable system which can be used by non-experts, between centres and across continents.

We have evaluated the in vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements which were undertaken in 155 patients. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem before line-to-line cementing. We used the Ein Bild Roentgen Analyse femoral component method to assess the subsidence of the femoral component.

At a mean of 17.3 years (15.1 to 18.3) 73 patients were still alive and had not been revised, eight had been revised, 66 had died and eight had been lost to follow-up. The mean subsidence of the entire series was 0.63 mm (0.0 to 1.94). When using a 1.5 mm threshold, only four stems were considered to have subsided. Our study showed that, in most cases, a highly polished double-tapered stem cemented line-to-line does not subside at least up to 18 years after implantation.

We report the outcome at ten to 15 years of two-stage revision for hip infection in 99 patients using the Prostalac articulated hip spacer system.

All the patients were contacted to determine their current functional and infection status using the Oxford-12, Short form-12, and Western Ontario and McMaster University Osteoarthritis Index questionnaires. A total of 11 of the 99 patients had a further infection, of whom seven responded to repeat surgery with no further sequelae. The mean interval between the stages was five months (1 to 36). We were able to review 48 living patients, with a mean age of 72 years (46 to 86), 34 (71%) of whom provided health-related quality-of-life outcome scores.

The mean follow-up was 12 years (10 to 15). The long-term success rate was 89% and with additional surgery this rose to 96%. The mean global Western Ontario and McMaster University Osteoarthritis Index score was 80.6 (sd 18.3). The mean Oxford-12 score was 74.0 (sd 22.3), and the mean Short form-12 score was 53.1 (sd 9.4) (mental) and 33.5 (sd 13.5) (physical). The mean satisfaction score was 90.5 (sd 15.3).

Two-stage revision for hip infection using a Prostalac interim spacer offers a predictable and lasting solution for patients with this difficult problem.

We describe 129 consecutive revision total hip replacements using a Charnley-Kerboull femoral component of standard length with impaction allografting. The mean follow-up was 8.2 years (2 to 16). Additionally, extramedullary reinforcement was performed using struts of cortical allograft in 49 hips and cerclage wires in 30.

There was one intra-operative fracture of the femur but none later. Two femoral components subsided by 5 mm and 8 mm respectively, and were considered to be radiological failures. No further revision of a femoral component was required. The rate of survival of the femoral component at nine years, using radiological failure as the endpoint, was 98%. Our study showed that impaction grafting in association with a Charnley-Kerboull femoral component has a low rate of subsidence. Reconstruction of deficiencies of distal bone with struts of cortical allograft appeared to be an efficient way of preventing postoperative femoral fracture for up to 16 years.

Bleeding is a major complication of revision total hip replacement. We report a case where the inflated balloon of a urinary catheter was used to temporarily control intrapelvic bleeding from the superior gluteal artery, while definitive measures for endovascular embolisation were made.

We reviewed the results of 71 revisions of the acetabular component in total hip replacement, using impaction of bone allograft. The mean follow-up was 7.2 years (1.6 to 9.7). All patients were assessed according to the American Academy of Orthopedic Surgeons (AAOS) classification of bone loss, the amount of bone graft required, thickness of the graft layer, signs of graft incorporation and use of augmentation. A total of 20 acetabular components required re-revision for aseptic loosening, giving an overall survival of 72% (95% CI, 54.4 to 80.5). Of these failures, 14 (70%) had an AAOS type III or IV bone defect. In the failed group, poor radiological and histological graft incorporation was seen. These results suggest that impaction allografting in acetabular revision with severe bone defects may have poorer results than have previously been reported

During revision total hip replacement using morcellised compacted bone allograft, 16 patients were randomised to receive a graft which had been rinsed in either an ibandronate solution or in saline. Patients were assessed by dual energy x-ray absorptiometry after operation and at 3, 6, 12 and 24 months. A region of interest between the tip of the femoral stem and the distal plastic plug was chosen to measure the changes in bone density over time. The study was double-blinded. In all the control patients the bone density decreased during the first three months and then remained constant at this lower level. A large proportion of the mass of the bone graft was lost. In contrast, all patients with grafts treated with bisphosphonate showed a slight increase in bone density. The difference between the groups was highly significant at all points in time. We conclude that rinsing the graft in a bisphosphonate solution prevents its resorption and may therefore reduce the risk of mechanical failure. The treatment is simple, inexpensive, and appears virtually free of risk

We assessed the outcome of patients with Vancouver type B2 and B3 periprosthetic fractures treated with femoral revision using an uncemented extensively porous-coated implant. A retrospective clinical and radiographic assessment of 22 patients with a mean follow-up of 33.7 months was performed. The mean time from the index procedure to fracture was 10.8 years. There were 17 patients with a satisfactory result. Complications in four patients included subsidence in two, deep sepsis in one, and delayed union in one. Concomitant acetabular revision was required in 19 patients. Uncemented extensively porous-coated femoral stems incorporate distally allowing stable fixation. We found good early survival rates and a low incidence of nonunion using this implant.

Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis.

The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.

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.

Iontophoresis is a novel technique which may be used to facilitate the movement of antibiotics into the substance of bone using an electrical potential applied externally. We have examined the rate of early infection in allografts following application of this technique in clinical practice. A total of 31 patients undergoing revision arthroplasty or surgery for limb salvage received 34 iontophoresed sequential allografts, of which 26 survived for a minimum of two years. The mean serum antibiotic levels after operation were low (gentamicin 0.37 mg/l (0.2 to 0.5); flucloxacillin 1 mg/l (0 to 1) and the levels in the drains were high (gentamicin 40 mg/l (2.5 to 131); flucloxacillin 17 mg/l (1 to 43). There were no early deep infections. Two late infections were presumed to be haemotogenous; 28 of the 34 allografts were retained. In 12 patients with pre-existing proven infection further infection has not occurred at a mean follow-up of 51 months (24 to 82).