Is Preoperative Identification of the Infecting Organism Essential Before Single-Stage Revision Hip Arthroplasty for Periprosthetic Infection?

BACKGROUND: It is commonly stated that identification of the infecting organism is a prerequisite to single-stage revision arthroplasty of the hip for deep infection. We have performed single-stage revision in a series of patients where the organism was not identified preoperatively. The aim of this study is to investigate whether the rate of infection eradication following single-stage revision was affected by preoperative knowledge of the infecting organism. METHODS: We identified all patients who had undergone a single-stage revision for a deep infection at our hospital between 2006 and 2015. One hundred five patients were assigned into 2 groups based upon whether the infecting organism had been identified preoperatively (group A = 28) or not (group B = 77). RESULTS: The reinfection rates were 3.6% in group A and 9.1% for group B (P = .679). Re-revision rates were 7.1% and 9.1%, respectively (P = 1.00). Overall, the implant survival rate at 6 years was 87.9% (95% confidence interval, 97.4-78.4). In group B, preoperative aspiration was performed in 36.4% (28/77) of cases. Staphylococci species were the predominant causative organisms, with gram-negative involvement in 19.0% (20/105) of cases. CONCLUSION: The rate of infection eradication and overall survivorship with single-stage revision was similar in our series to that reported in the literature. While desirable, we did not find identification of the infecting organism before surgery influenced the outcome. Given the functional and economic benefits of single-stage revision, we suggest that failure to identify an organism is not an absolute contraindication to this approach.

Survivorship and Radiological Analysis of a Monoblock, Hydroxyapatite-Coated Titanium Stem in Revision Hip Arthroplasty.

BACKGROUND: We evaluated the survivorship, incidence of complications, radiological subsidence, proximal stress shielding, and patient-reported outcomes of a conservative, monoblock, hydroxyapatite-coated femoral stem. METHODS: This retrospective cohort study reports on 254 revision hip arthroplasties between January 2006 and June 2016. The mean age of patients was 71 years. The mean length of follow-up was 62 months (range 12-152). RESULTS: There were 13 stem re-revisions: infection (4), periprosthetic fracture (4), aseptic stem loosening (3), stem fracture (1), and extended trochanteric osteotomy nonunion (1). Kaplan-Meier aseptic stem survivorship was 97.33% (confidence interval 94-100) at 6 years. There were 29 intraoperative fractures. There were 6 cases of subsidence greater than 10 mm; however, none required revision. Ninety-six percent of cases showed no proximal stress shielding. Thigh pain was reported in 3% of cases. CONCLUSION: This study confirms that this stem provides good survivorship at 6 years, acceptable complication rates, adequate proximal bone loading, low incidences of thigh pain, and reliable clinical performance in revision hip arthroplasty. KEY MESSAGE: A monoblock, fully hydroxyapatite-coated titanium stem is reliable in revision arthroplasty with mild-moderate femur deficiencies.

Outcomes of Cement in Cement Revision, in Revision Total Hip Arthroplasty.

BACKGROUND: The cement-in-cement femoral revision technique involves removing a femoral component from a well-fixed femoral cement mantle and cementing a new stem into the original mantle. This technique, when carried out for the correct indications, is fast, relatively inexpensive and carries a reduced short-term risk for the patient compared with conventional way of removing well-fixed cement. AIM: To analyze the effectiveness of cement in cement revision of the femoral stem while performing a revision Total Hip Arthroplasty (THA). METHODS: We analyzed a consecutive series of 79 patients who underwent a cement in cement revision THA between June-2015 to June-2018. All the patients were retrospectively analysed for operative time, complications, clinical and radiological outcomes. RESULTS: Average age was 76 years (49-86). The mean follow-up was 16.2 months (12-45). The average operative time was 184.6 (90-290) minutes. Most common indication was cup loosening in 28 patients (42.4%), dislocation in 14 patients (21.2%) and stem loosening in 12 patients (18.2%) Nine patients (11%) had one or more complications. Pre-operatively, 10 patients (13%) had lucency at the cement bone interface. Recent review has shown that 8 of these patients' radiographs have remained unchanged, and in 2 of them there is a slight progression of lucency. Common post op clinical complaintswere persistent pain and abductor weakness. Five (6.3%) patients required a re-revision. Most of the patients had a good or satisfactory outcome.No stems showed radiological loosening. CONCLUSION: The cement-in-cement technique for revision of the femoral component gave promising results and had the advantages of speed, less blood or bone stock loss, less risk of femoral perforation or fracture, decreased financial costs and reduced post op morbidity.

Acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts.

PURPOSE: To review the outcome of acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts in 15 patients. METHODS: Records were reviewed for 3 men and 12 women aged 31 to 72 (mean, 53) years who underwent acetabular revision with bone grafting and cementation for aseptic loosening at a mean of 12.4 (range, 6.6-20.3) years after primary Charnley low-friction hip arthroplasty with superolateral structural bulk autografts from the femoral head for dysplastic hip (n=14) or bone loss secondary to acetabular fracture (n=1). RESULTS: After a mean follow-up of 6.7 (range, 1.1-14.5) years, the mean Merle d'Aubigné and Postel score improved from 8.55 to 16.5. Bridging trabeculae was noted in 10 hips and graft remodelling in 5 hips. Five hips had ectopic ossification of Brooker grade 1 to 2. The mean hip centre of rotation was 21.6 (range, 16.2-30.6) mm. Two women required re-revision for aseptic loosening of the acetabulum after 8.5 and 6.6 years. The first one underwent re-revision with solid allograft for superolateral deficiency of the acetabulum. The second one underwent re-revision with solid and morselised bone allografts for loosened acetabulum. One patient had superior migrationof the acetabulum for 9 mm at year 2, but it was asymptomatic. One patient had a dislocation that was reduced with manipulation under anaesthesia. Threepatients had trochanteric non-union and presented with lateral thigh pain and tenderness, but no further surgery was performed. CONCLUSION: The medium-term outcome of acetabular revision with bone grafting and cementation is satisfactory. Repeat bone grafting is required to restore the anatomic acetabular position and bone loss secondary to acetabular loosening.

The C-stem in clinical practice: fifteen-year follow-up of a triple tapered polished cemented stem.

The triple tapered polished cemented stem, C-Stem, introduced in 1993 was based on the original Charnley concept of the "flat back" polished stem. We present our continuing experience with the C-Stem in 621 consecutive primary arthroplasties implanted into 575 patients between 1993 and 1997. Four hundred and eighteen arthroplasties had a clinical and radiological follow-up past 10 years with a mean follow-up of 13 years (10-15). There were no revisions for stem loosening but 2 stems were revised for fracture - both with a defective cement mantle proximally. The stem design and the surgical technique support the original Charnley concept of limited stem subsidence within the cement mantle and the encouraging results continue to stand as a credit to Sir John Charnley's original philosophy.

Effect of reduced diameter neck stem on incidence of radiographic cup loosening and revisions in Charnley low-frictional torque arthroplasty.

Previous studies of the Charnley low-frictional torque arthroplasty have established an exponential correlation between the depth of cup penetration and the incidence of ultrahigh molecular weight polyethylene cemented cup migration. Impingement of the neck of the stem on the rim of the cup was considered to be the cause. We compared the incidence of radiographic loosening and revision of the cup in 2 groups of patients: those with 12.5-mm-diameter neck stem (972 hips) and those with 10-mm-diameter neck stem (261 hips) over a 20-year period, at comparable depths of cup penetration. The benefit of the 10-mm-diameter neck could be expressed as delaying radiographic loosening and revision of the cup by approximately 2 mm of cup penetration because loosening occurred at 2 mm penetration with a 12.5-mm-diameter neck but not until 4-mm penetration with a 10-mm-diameter neck. When a particular depth of cup penetration is reached will clearly depend on factors affecting wear.

Charnley low-frictional torque arthroplasty in young rheumatoid and juvenile rheumatoid arthritis: 292 hips followed for an average of 15 years.

INTRODUCTION: In the early 1960s, Charnley was cautious with his patient selection for total hip replacement. As follow-up increased and confidence in the operation grew, younger patients were selected. We present our results of the Charnley LFA in young patients with rheumatoid and juvenile rheumatoid arthritis with a followup of up to 36 years. PATIENTS: We studied 292 Charnley low-friction arthroplasties in 195 young patients with an established diagnosis of rheumatoid arthritis. Their mean age at operation was 38 (12-50) years; 168 (58%) were receiving steroids and 79 (27%) were on non-steroidal antiinflammatory medication. The mean follow-up for the whole group was 15 (1-36) years. 24 patients could not be traced (33 hips), and 61 patients died (88 hips). RESULTS: 25 patients (41 hips) had had a revision. The main indication for revision was cup loosening. In the 85 patients (130 hips) attending follow-up, their mean age at surgery was 36 (17-50) years and the mean follow-up was 20 (10-36) years. 98% were pain-free or had no more than occasional discomfort, 44% claimed to have normal or near-normal function, while 62% had full or almost full range of movement of the replaced hip. Radiographically, 29 cups (22%) were considered to be loose. 1 stem (1%) was definitely loose and 2 stems (2%) were probably loose. With revision for any indication as the endpoint, the survival was 74% at 25 years follow-up. INTERPRETATION: The Charnley LFA continues to be an excellent hip replacement, even for very young rheumatoid arthritis patients. Wear and aseptic cup loosening are the main long-term problems.

Charnley low-frictional torque arthroplasty for avascular necrosis of the femoral head.

Forty-nine patients (mean age, 37 years; 20-50 years) had had 69 Charnley low-frictional arthroplasties for avascular necrosis of the femoral head. Their mean follow-up was 13.4 years (2-25 years). Five patients (8 hips) had no continuing follow-up, 5 (8 hips) are known to have died, 6 (7 hips) had had a revision at a mean follow-up of 16.4 years (11-25 years): 6 for cup loosening and 1 for a fractured stem and a loose cup. The remaining 33 patients (46 hips) had an excellent clinical result with all stems remaining soundly fixed, but 6 cups were radiologically loose at a mean follow-up of 16 years and 4 months. Wear and cup loosening are the main problems limiting the survival of the arthroplasty.

Wear of ultra-high-molecular-weight polyethylene cup articulating with 22.225 mm zirconia diameter head in cemented total hip arthroplasty.

A number of studies have highlighted the increasing incidence of aseptic cup loosening with increasing depth of cup penetration by the metal head. We present our experience with a 22.225 mm diameter zirconia head on a 9-10 taper articulating with an ultra-high-molecular-weight polyethylene (UHMWPE) cup in cemented total hip arthroplasties. We prospectively studied the wear of the UHMWPE cup articulating with a 22.225 mm diameter zirconia head in cemented total hip arthroplasties. A total of 339 patients (153 men, 186 women, 373 hips) were included. The patients' mean age at surgery was 52 years (17-76 years), with 41% age 50 years or younger. Their mean weight was 72.4 kg (24-125 kg). At a mean follow-up of 4.3 years (0-8 years) the mean penetration rate of the cup was 0.03 mm/year (0-0.51 mm/year). Altogether, 289 (77.5%) showed no measurable wear, 38 (10.2%) had a penetration rate of 0.11 mm/year or less, 33 (8.9%) had a rate of 0.12-0.2 mm/year, and in 13 (3.5%) the rate was more than 0.2 mm/year. Ceramic-UHMWPE is the next stage in the evolution of total hip arthroplasty for addressing wear and any possible related issues.