Midterm survival analysis of a cemented dual-mobility cup combined with bone impaction grafting in 102 revision hip arthroplasties.

INTRODUCTION: Revision hip arthroplasty is associated with higher dislocation rates than primary hip arthroplasty. A dual-mobility cup (DMC) can reduce this risk. Another problem is destruction of the acetabulum, induced by aseptic loosening of the prosthesis. Bone impaction grafting (BIG) can be used to reconstruct these defects, but is usually performed with cemented all polyethylene cups. The purpose of this study is to evaluate midterm cup survival and dislocation rate for the combination of BIG and DMC. METHODS: Between 2007 and 2013, 96 patients received 102 DMCs combined with BIG of the acetabulum during revision surgery. These data were first compared with a control group, consisting of 59 cases from the same hospital receiving a cemented all polyethylene cup combined with BIG. In addition, the control group was expanded with 41 cases operated on in 2007 in 'an orthopaedic centre of excellence', resulting in a 'combined control group' of 100 patients. Log-rank tests and chi-square tests were used to compare survival and dislocation rates, respectively. RESULTS: Cumulative survival of the DMC was 95.8% (range 3 months-7 years). This was comparable to the survival in the control groups (96.5% and 94.7%). The dislocation rate of 2.9% (3/102) in the dual-mobility group was lower (p = 0.02) compared to the dislocation rate of 11.8% (7/59) in the control group, but not (p = 0.12) compared to 8% in the combined control group (8/100). CONCLUSIONS: This study shows that combining a DMC with BIG does not compromise outcome in terms of midterm survival of the cup.

Predictors of unsuccessful outcome in cemented femoral revisions using bone impaction grafting; Cox regression analysis of 208 cases.

INTRODUCTION: Despite improvements in the technique of femoral impaction bone grafting, reconstruction failures still can occur. Therefore, the aim of our study was to determine risk factors for the endpoint re-revision for any reason. METHODS: We used prospectively collected demographic, clinical and surgical data of all 202 patients who underwent 208 femoral revisions using the X-change Femoral Revision System (Stryker-Howmedica), fresh-frozen morcellised allograft and a cemented polished Exeter stem in our department from 1991 to 2007. Univariable and multivariable Cox regression analyses were performed to identify potential factors associated with re-revision. RESULTS: The mean follow-up was 10.6 (5-21) years. The cumulative re-revision rate was 6.3% (13/208). After univariable selection, sex, age, body mass index (BMI), American Association of Anesthesiologists (ASA) classification, type of removed femoral component, and mesh used for reconstruction were included in multivariable regression analysis.In the multivariable analysis, BMI was the only factor that was significantly associated with the risk of re-revision after bone impaction grafting (BMI ≥30 vs. BMI <30, HR = 6.54 [95% CI 1.89-22.65]; p = 0.003). CONCLUSIONS: BMI was the only factor associated with the risk of re-revision for any reason. Besides BMI also other factors, such as Endoklinik score and the type of removed femoral component, can provide guidance in the process of preclinical decision making. With the knowledge obtained from this study, preoperative patient selection, informed consent, and treatment protocols can be better adjusted to the individual patient who needs to undergo a femoral revision with impaction bone grafting.

Medium-term follow-up of 92 femoral component revisions using a third-generation cementing technique.

BACKGROUND AND PURPOSE: Very little has been published on the outcome of femoral cemented revisions using a third-generation cementing technique. We report the medium-term outcome of a consecutive series of patients treated in this way. PATIENTS AND METHODS: This study included 92 consecutive cemented femoral revisions performed in our department with a third-generation cementing technique and without instrumented bone impaction grafting between 1996 and 2007. The average age of the patients at revision was 66 (25-92) years. None of the patients were lost to follow-up. At review in December 2013, 55 patients were still alive and had a non-re-revised femoral revision component in situ after a mean follow-up of 11 (5-17) years. RESULTS: The mean preoperative Harris hip score was 50, and improved to 73 at final follow-up. 2 patients died shortly after the revision surgery. 1 stem was re-revised for aseptic loosening; this was also the only case with radiolucent lines in all 7 Gruen zones. A femoral reoperation was performed in 19 hips during follow-up, and in 14 of these 19 reoperations the femoral component was re-revised. Survivorship at 10 years, with femoral re-revision for any reason as the endpoint, was 86% (95% CI: 77-92). However, excluding 8 patients with reinfections after septic index revisions and 1 with hematogenous spread of infection from the survival analysis, the adjusted survival for re-revision for any reason at 10 years was 92% (95% CI: 83-96). With re-revision for aseptic loosening as endpoint, the survival at 10 years was 99% (CI: 90-100). INTERPRETATION: Femoral component revision with a third-generation cemented stem results in acceptable survival after medium-term follow-up. We recommend the use of this technique in femoral revisions with limited loss of bone stock.

Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients.

BACKGROUND: The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far. QUESTIONS/PURPOSES: The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old. METHODS: During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate. RESULTS: The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%-95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%-100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised. CONCLUSIONS: IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Cemented total hip arthroplasty revisions in patients of eighty years and older.

PURPOSE: It is often a difficult decision whether it is safe to perform revision hip surgery in a patient of 80 years and older. Therefore we evaluated the results of cemented revisions in these elderly patients. METHODS: Clinical data, radiographs and complications of 49 consecutive cup and/or stem revisions in 48 patients were prospectively collected. The average age of the patients at surgery was 84 years (range, 80-92). We performed Kaplan-Meier (KM) analysis and also a competing risk (CR) analysis because in this series the presence of a competing event (i.e. death) prevents the occurrence of endpoint rerevision. RESULTS: Twenty-nine patients (30 hips) died without rerevision during follow-up and their data was included. The average follow-up of the 16 surviving patients was eight years (range, six to 13). Six re-operations were performed, of which three were re-revisions. Eight-year survivorship was 91.6% (95% confidence interval (CI) 76-97%) for endpoint re-revision for any reason. With the CR analysis we calculated that due to the increasing number of competing events, the KM analysis overestimates the failure rate with 32% for this endpoint. The average Harris hip score improved from 49 to 74. Mortality within three months after surgery was 6%. One postoperative fracture occurred and six hips dislocated. CONCLUSION: Cemented revisions can provide satisfying results in patient of 80 years and older with acceptable survivorship and complication rates.

Acetabular re-revision with impaction bone grafting and a cemented polyethylene cup; a biological option for successive reconstructions.

INTRODUCTION: For the revision of failed acetabular components impaction bone grafting (IBG) with a cemented cup is a well known technique. Claims have been made that this is a biological reconstruction technique, restoring the bone stock loss and thereby facilitating future revisions. However, there are no scientific data proving this claim. PATIENTS AND METHODS: In this study, we present the clinical and radiographic outcome of 11 consecutive acetabular re-revisions in 10 patients with again IBG and a cemented polyethylene cup observed in a previously reported cohort of 62 acetabular IBG revisions. All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. RESULTS: The mean follow-up after re-revision was 10 years (5-15) and 28 years (26-30) after the primary revision. No patients were lost to follow-up. The mean HHS improved from 37 (12-49) points to 71 (40-95) points at final follow-up. Survival with further cup revision for any reason as endpoint was 91% (95% confidence interval (CI) 51 to 99) at 10 years. When excluding one early cup re-revision for malpositioning 3 weeks postoperative, survivorship with further cup revision for aseptic loosening as endpoint was 100% (95% CI 37-100) at 10 years. Survival with further cup re-operation for any reason as endpoint was 82% (95% one-sided CI 45-95). In all surviving re-revisions trabecular incorporation was observed without radiolucent lines. CONCLUSION: This study shows that, due to restoring the bone stock, even successive acetabular reconstructions using IBG and a cemented cup are possible with satisfying 10 years survivorship.

Impaction bone grafting and a cemented cup after acetabular fracture.

PURPOSE: Patients suffering from post traumatic osteoarthritis of the acetabulum often require a total hip arthroplasty at a relatively young age. Long-term data outcome studies for this population are lacking. We report on the long-term outcome of 20 acetabular fractures in 20 patients treated with impaction bone grafting and a cemented cup after a mean follow-up of 18 years (range, 12-26 years). METHODS: The group consisted of 14 males (70%) and six females (30%) with an average age of 53.3 years (range, 35-75 years) at time of surgery. No patients were lost to follow-up. Four patients died and three patients underwent a revision; at review 13 patients were still living with their implant in situ. Survivorship analysis was performed at 20 years follow-up for three endpoints. RESULTS: Survival rate with endpoint revision for any reason at 20 years postoperative was 74.7% (95% confidence interval (CI), 40-91%), 80.0% (95% CI, 41-95%) for endpoint aseptic loosening, and 63.9% (95% CI 32-84%) for endpoint radiographic failure. Three acetabular components were revised at 14.5, 15.3, and 16.7 years postoperative. Two cups failed for aseptic loosening and one cup failed due to septic loosening. The average postoperative Harris hip score was 82 (range, 56-100). CONCLUSION: Acetabular reconstruction with impaction bone grafting and the use of a cemented cup after acetabular fracture is an attractive technique with acceptable long-term results and a low complication and re-operation rate.

Cement-in-cement femoral revisions using a specially designed polished short revision stem; 24 consecutive stems followed for five to seven years.

Femoral cement-in-cement revisions are attractive if the cement bone mantle is well fixed. However, most available cemented stems are too long to fit in the existing cement mantle. We evaluated the medium-term outcomes of the 125 mm short tapered polished stem (Exeter Short Revision Stem (SRS)) with a 44 mm offset specifically designed to facilitate cement-in-cement revisions of hip arthroplasties. The Exeter SRS was clinically and radiographically evaluated in 24 consecutive femoral cement-in-cement revisions (11 men, 13 women) between July 2005 and February 2008 after a mean follow-up of six years (5-7). The mean age at operation was 67 years (54-83). No hip was lost to follow-up, but two patients (two hips) died. None of the deaths were related to the surgery. Kaplan Meier survival analysis was performed. Four femoral components (17%) were removed for septic loosening after a mean of 2.4 years (0.8-4.9). Three of these hips were revised again in a two-stage revision, and one was converted to a permanent excision arthroplasty. The probability of survival with re-revision for any reason was 82% (95% CI: 58-93) and survivorship with aseptic loosening as the endpoint was 100% at six years. There were no additional radiological failures. The Exeter Short Revision Stem is a valuable option for simplifying cement-in-cement revisions. Despite the short stem length, at mid-term there were no signs of instability or aseptic loosening.

Femoral component revision with use of impaction bone-grafting and a cemented polished stem: a concise follow-up, at fifteen to twenty years, of a previous report.

We previously reported our results for thirty-three consecutive femoral component revisions with impaction bone-grafting, performed with the X-change femoral revision system and a cemented polished Exeter stem, at a minimum of eight years of follow-up. The present updated study shows the results after fifteen to twenty years. One stem was revised again for mechanical reasons during a rerevision of an acetabular cup. The probability of survival at seventeen years was 96% (95% confidence interval [CI], 72% to 99%) with a femoral rerevision for any reason as the end point and 100% (95% one-sided CI, 69% to 100%) with rerevision for aseptic loosening as the end point. The average subsidence was 3 mm and stable relative to our previous report. Although three early femoral fractures occurred after this surgery, in this update no additional fractures were seen. In conclusion, the probability of survival of femoral component revisions with impaction bone-grafting and a cemented polished stem was excellent at a mean of seventeen years.

The value of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures.

This study aimed to evaluate the intra- and interobserver agreement for both fracture classification according to Schatzker and treatment plan of tibial plateau fractures using plain radiographs alone and with computed tomography (CT) scans. The study was carried out prospectively to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. Eight experienced observers (six surgeons and two radiologists) classified 15 tibial plateau fractures with plain radiographs and CT scans and set up a treatment plan. Agreement was measured using kappa coefficients. Using plain radiographs alone, the mean interobserver kappa coefficient for classification was 0.47, which decreased to 0.46 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.40, which decreased to 0.30 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain radiographs was 0.60, which decreased to 0.57 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain radiographs alone was 0.53, which decreased to 0.45 after addition of CT scans. In contrast with other recent publications, there is no increase in inter- and intra-agreement of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Routine CT scanning of the knee for tibial plateau fractures is not supported by this study.

[Open lateral clavicle resection in acromioclavicular osteoarthritis: favourable results after 1 year]. / Open laterale clavicularesectie bij acromioclaviculaire artrose: gunstige resultaten na 1 jaar.

OBJECTIVE: To determine the follow-up outcomes of open lateral clavicle resection 1 year postoperatively in patients with acromioclavicular osteoarthritis. The operation involves resection of a small part of the lateral clavicle. DESIGN: Prospective descriptive. METHOD: Data were collected from all patients who had undergone an open lateral clavicle resection in the period July 1999 to June 2008 and who were examined preoperatively and 1 year postoperatively. This concerned 23 operations in 22 patients. The Constant score for the functionality of the shoulder was determined and visual analogue scales (VAS) were used to determine the pain and satisfaction concerning the operated shoulder. The results were evaluated with the paired t-test and the non-parametric Wilcoxon test. RESULTS: The mean length of the lateral clavicle resection was 7.8 mm. Preoperatively the mean Constant score was 64 (SD: 14) and 1 year after the operation 86 (SD: 14; p < 0.001). Ninety-one percent had an increase in the postoperative Constant score compared with the preoperative score. The median VAS score for pain decreased from 70 (95% CI: 60-77) preoperatively to 25 (0-48) 1 year postoperatively (p < 0.001). The median VAS score for satisfaction increased from 40 (40-50) preoperatively to 85 (68-100) (p < 0.001). CONCLUSION: The open lateral clavicle resection was a treatment option to reduce the symptoms in patients with acromioclavicular osteoarthritis in whom conservative treatment and medication proved to be insufficient.