We describe a new technique of reconstruction of the deficient acetabulum in cementless total hip arthroplasty. The outer iliac table just above the deficient acetabulum is osteotomised and slid downwards. We have termed this an iliac sliding graft. Between October 1997 and November 2001, cementless total hip arthroplasty with an iliac sliding graft was performed on 19 patients (19 hips) with acetabular dysplasia. The mean follow-up was 3.4 years (2 to 6). The mean pre-operative Harris hip score was 45.1 which improved significantly to 85.3 at the time of the final follow-up. No patient had post-operative abductor dysfunction.
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.
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).
Interleukin (IL)-1β is one of the major pathogenic regulators during the pathological development of intervertebral disc degeneration (IDD). However, effective treatment options for IDD are limited. Suramin is used to treat African sleeping sickness. This study aimed to investigate the pharmacological effects of suramin on mitigating IDD and to characterize the underlying mechanism. Porcine nucleus pulposus (NP) cells were treated with vehicle, 10 ng/ml IL-1β, 10 μM suramin, or 10 μM suramin plus IL-1β. The expression levels of catabolic and anabolic proteins, proinflammatory cytokines, mitogen-activated protein kinase (MAPK), and nuclear factor (NF)-κB-related signalling molecules were assessed by Western blotting, quantitative real-time polymerase chain reaction (qRT-PCR), and immunofluorescence analysis. Flow cytometry was applied to detect apoptotic cells. The ex vivo effects of suramin were examined using IDD organ culture and differentiation was analyzed by Safranin O-Fast green and Alcian blue staining.Aims
Methods
Femoral impaction bone grafting was first developed in 1987 using
morselised cancellous bone graft impacted into the femoral canal
in combination with a cemented, tapered, polished stem. We describe
the evolution of this technique and instrumentation since that time. Between 1987 and 2005, 705 revision total hip arthroplasties
(56 bilateral) were performed with femoral impaction grafting using
a cemented femoral stem. All surviving patients were prospectively
followed for a mean of 14.7 years (9.8 to 28.3) with no loss to
follow-up. By the time of the final review, 404 patients had died.Aims
Patients and Methods
We describe the results of 81 consecutive revision
total hip replacements with impaction grafting in 79 patients using
a collared polished chrome–cobalt stem, customised in length according
to the extent of distal bone loss. Our hypothesis was that the features
of this stem would reduce the rate of femoral fracture and subsidence
of the stem. The mean follow-up was 12 years (8 to 15). No intra-operative
fracture or significant subsidence occurred. Only one patient suffered
a post-operative diaphyseal fracture, which was associated with
a fall. All but one femur showed incorporation of the graft. No
revision for aseptic loosening was recorded. The rate of survival of the femoral component at 12 years, using
further femoral revision as the endpoint, was 100% (95% confidence
interval (CI) 95.9 to 100), and at nine years using re-operation
for any reason as the endpoint, was 94.6% (95% CI 92.0 to 97.2). These results suggest that a customised cemented polished stem
individually adapted to the extent of bone loss and with a collar
may reduce subsidence and the rate of fracture while maintaining
the durability of the fixation.
We present the results of 62 consecutive acetabular
revisions using impaction bone grafting and a cemented polyethylene
acetabular component in 58 patients (13 men and 45 women) after
a mean follow-up of 27 years (25 to 30). All patients were prospectively
followed. The mean age at revision was 59.2 years (23 to 82). We performed Kaplan–Meier (KM) analysis and also a Competing
Risk (CR) analysis because with long-term follow-up, the presence
of a competing event (i.e. death) prevents the occurrence of the
endpoint of re-revision. A total of 48 patients (52 hips) had died or had been re-revised
at final review in March 2011. None of the deaths were related to
the surgery. The mean Harris hip score of the ten surviving hips
in ten patients was 76 points (45 to 99). The KM survivorship at 25 years for the endpoint ‘re-revision
for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73)
and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to
85). With the CR analysis we calculated the KM analysis overestimates
the failure rate with respectively 74% and 93% for these endpoints.
The current study shows that acetabular impaction bone grafting
revisions provide good clinical results at over 25 years. Cite this article:
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 present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.
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.
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.
