Outcomes of Osteochondral Allograft Transplantation for Femoral Head Cartilage Lesions: Minimum 2-year Follow-up.

BACKGROUND: The surgical management of large osteochondral lesions of the femoral head in young, active patients remains controversial. Fresh osteochondral allograft (OCA) transplantation can be a highly effective treatment for these lesions in some patients. This study investigated survivorship as well as clinical and radiographic outcomes after fresh OCA transplantation at a minimum 2-year follow-up (mean, 6.6 years; range, 0.6-13.7 years). METHODS: A retrospective review of 29 patients who underwent plug OCA transplantation for focal femoral head osteochondral lesions between 2008 and 2021 was performed. Patients were assessed clinically using the modified Harris Hip Score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and osteoarthritis severity. Kaplan-Meier survivorship analyses with 95% confidence intervals were performed for the endpoint of conversion to total hip arthroplasty (THA). RESULTS: Overall graft survivorship for included patients was 78.4% (95% CI: 62.9 to 93.9) and 62.7% (95% CI: 39.6 to 85.8) at 5 and 10 years, respectively. There were ten patients (34.5%) who underwent conversion to THA. There was a significant difference using the log-rank test between survival for patients who had a preoperative diagnosis of osteonecrosis (ON) versus those who had other diagnoses (P = 0.002). The ten-year survival for those who had ON was 41.8% (95% CI: 4.8 to 78.8), and the ten-year survival for diagnoses other than ON was 85.7% (95% CI: 59.8 to 100). The mean mHHS score improved significantly (P < 0.001) from 48.9 (19 to 84) pre-operatively to 77.4 (35 to 100) at final follow-up. There were twenty patients (69.0%) who had an mHHS ≥ 70 at the latest follow-up. Arthritic progression, indicated by an increase in the KL grade, occurred in seven hips (26.9%). CONCLUSION: An OCA transplantation is a viable treatment option for osteochondral defects of the femoral head in young, active patients who have minimal preexisting joint deformity. It may delay the progression of arthritis and the need for THA. Patients who had a preoperative diagnosis of ON had worse clinical outcomes than those who had other diagnoses.

Clinical and Functional Outcomes of Extended Trochanteric Osteotomy in 2-Stage Revision Total Hip Arthroplasty for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Extended trochanteric osteotomy (ETO) has long been used in 2-stage revision surgeries of the hip, for both aseptic and septic indications. The purpose of this systematic review is to summarize the cumulative occurrence rates of the clinical and functional outcomes associated with the use of ETO in 2-stage revision total hip arthroplasty for periprosthetic joint infection. METHODS: PubMed/MEDLINE and the Cochrane Database of Systematic Reviews databases were searched for articles published from January 1980 to January 2022 using the following keywords: "extended" AND "trochanteric" AND "osteotomy" AND "infection." Cumulative occurrence rates of outcomes and complications were calculated. A fixed-effects model and a 95% CI were applied. A P value of .05 was considered the significance threshold. RESULTS: Nine studies were in full compliance with the inclusion criteria, with a total population size across all studies of 378. Union and infection eradication rates among studies were 95.1% (95% CI, 92.7-97.1, P = .018) and 94.0% (95% CI, 91.1-96.4, P = .089), respectively. Postoperation complications occurred in 15.34% of patients (95% CI, 10.34-21.22, P = .066). Occurrence rates for stem subsidence, dislocation, and femoral fractures were 6.2% (95% CI, 3.3-9.9, P = .187), 7.6% (95% CI, 4.8-10.9, P = .075), and 9.1% (95% CI, 5.8-13, P = .106), respectively. CONCLUSION: With high rates of union and infection eradication, and low rates of postoperation complications, this study concludes the use of ETO in performing 2-stage revision total hip arthroplasty for the septic hip to be effective and safe.

Subsidence of a Single-Taper Femoral Stem in Primary Total Hip Arthroplasty: Characterization, Associated Factors, and Sequelae.

BACKGROUND: We characterized subsidence of an uncemented single-taper femoral stem in primary total hip arthroplasty (THA), determined factors associated with subsidence, and evaluated the impact of subsidence on outcome. METHODS: This retrospective study included 502 primary THAs performed using a single-taper stem in Dorr type-A and type-B femora between 2014 and 2018. Subsidence was measured based on distance from the greater trochanter to stem shoulder on calibrated X-rays. Demographics, case-specific data, and outcomes were collected. Changes in subsidence and variables associated with subsidence were determined. RESULTS: Stem subsidence was 1.5 ± 2.3 mm, 1.6 ± 2.0 mm, 2.0 ± 2.6 mm, 2.3 ± 2.3 mm, 2.6 ± 2.5 mm, and 2.7 ± 3.0 mm at 6 weeks, 3 months, 6 months, 1 year, 2 years, and ≥3 years from THA, respectively. Subsidence across all patients at final mean follow-up of 24 months (range, 1 to 101 months) was 2.2 ± 2.6 mm. Pairwise comparison demonstrated that subsidence occurred predominantly within the first 6 months. Significant subsidence (≥5 mm) occurred in 17.3% and was associated with a body mass index (BMI) ≥25 (P = .04). Dorr type, age, sex, and American Society of Anesthesiologists class were not associated with subsidence. There were 2 patients (0.4%) who underwent a revision that could be attributed to subsidence. There was no association between subsidence and pain, limp, need for ambulatory aid, or analgesic use. CONCLUSION: In primary THAs performed using a single-taper prosthesis, average subsidence was 2.2 mm and significant subsidence occurred in 17.3%. Patient BMI was associated with subsidence. Revision surgery related to subsidence was infrequent (0.4%).

Hip Arthroplasty With the Use of a Reconstruction Cage and Porous Metal Augment to Treat Massive Acetabular Bone Loss: A Midterm Follow-Up.

BACKGROUND: Acetabular reconstruction in the context of massive acetabular bone loss is challenging. In rare scenarios where the extent of bone loss precludes shell placement (cup-cage), reconstruction at our center consisted of a cage combined with highly porous metal augments. This study evaluates survivorship, complications, and functional outcomes using this technique. METHODS: Patients with minimum 2-year follow-up were included. Baseline characteristics were collected. Preintervention and postintervention ambulatory scores were collected. Kaplan-Meier (KM) survival analysis for cage failure requiring revision surgery was conducted. Binomial regression analysis was performed to assess for correlation of aseptic cage failure with baseline characteristics. Preintervention and postintervention ambulatory aid requirements were compared. RESULTS: A total of 41 patients were identified. Mean follow-up was 6.4 years (range 2.8-11.0). Four (9.8%) aseptic cage revisions were identified. Aseptic KM survival analysis was 87.4% (95% confidence interval 75.3-99.6) at 10 years. Aseptic KM survival was 45.0% versus 92.8% at 9 years (P = .14) for patients with vs without pelvic discontinuity. KM survival for all-cause failure was 61.6% (95% confidence interval 44.0-79.2) at 10 years. Binomial regression did not demonstrate correlation of cage failure with baseline characteristics. Wilcoxon signed-rank test demonstrated a significant reduction in ambulatory aide requirement after surgery (mean rank 11.47 vs 9.00, Z = -2.95, P = .003). CONCLUSION: In scenarios of massive acetabular bone loss where a cup-cage is not a viable option, good survivorship free from aseptic cage failure can be expected at mid-term follow-up using an antiprotrusio cage combined with porous metal augments. Success requires extensive experience in revision surgery.

Does Revision of an Acetabular Shell With Insertion of an Uncemented Constrained Liner Confer Benefit Over Cementing Into a Well-Ingrown Shell?

BACKGROUND: During revision total hip arthroplasty (THA), a constrained acetabular liner (CAL) may be inserted to enhance hip stability. It is unclear, however, whether cementation of a CAL into a retained cup offers an advantage compared to revision of the acetabular cup and insertion of an uncemented CAL. The purpose of our study was to compare outcomes and survivorship between the 2 methods. METHODS: We identified a total of 177 patients who underwent revision THA with a specific CAL at our center between July 2004 and May 2019 (114 cup revisions and insertion of an uncemented CAL, 63 cementations of a CAL into a retained cup). Kaplan-Meier (KM) survival analysis was performed for implant survival free from aseptic failure of the CAL for both cohorts. RESULTS: The average follow-up time was 7.2 and 7.02 years for the cemented and uncemented cohort, respectively (P = .55). Five patients (7.93%) in the cemented CAL group experienced failure of the CAL, whereas 10 patients (8.77%) in the uncemented CAL cohort experienced failure (P = .21). Kaplan-Meier (KM) survival analysis demonstrated comparable survivorship at 10 years (P = .055). CONCLUSION: The results of our study suggest comparable survivorship between cementing a CAL into a retained cup and inserting an uncemented CAL in a revised acetabular cup. As a result of these findings along with the benefits associated with cementing a CAL, we encourage surgeons to readily consider this option in the management of recurrent instability.

Surgical Technique: Abductor Reconstruction With Gluteus Maximus and Tensor Fascia Lata in Revision Total Hip Arthroplasty.

BACKGROUND: Abductor deficiency in revision total hip arthroplasty (THA) is a common problem that can lead to pain, limping, and instability. Repair and reconstruction of the abductors is challenging, with a high rate of failure reported in the literature. The purpose of this study is to describe a simplified technique of abductor repair augmented with the transfer of gluteus maximus (Gmax) and the tensor fascia lata (TFL). METHODS: We describe a novel abductor reconstruction with transfer of the anterior 30% of Gmax and the posterior 70% of TFL to the vastus lateralis origin. These transfers can be used in isolation or to augment repair of torn abductors to the greater trochanter. The technique is simple and quick to perform via a lateral approach, requiring dissection of only two muscle slips and minimal additional soft tissue dissection. RESULTS: We describe the use and outcomes of this technique on three patients undergoing revision THA with severe and irreparable abductor deficiency. Although these patients reported improved function after the reconstruction, there was persistence of mild to moderate limping. CONCLUSION: Abductor reconstruction with partial transfers of Gmax and TFL is a promising approach to manage abductor deficiency in revision THA. Larger series are required to determine the efficacy of this technique for restoring abductor function and improving patient reported outcomes.

Mid-term outcomes of the Wagner Cone Prosthesis™ stem for developmental dysplasia of the hip: minimum two year follow-up.

PURPOSE: Treatment of symptomatic developmental dysplasia of the hip (DDH) requires a technically demanding total hip arthroplasty (THA) reconstruction. In patients with DDH, prostheses can be difficult to implant and often face the risk of fracture, mismatch, and loosening. The Wagner Cone Prosthesis™ is a tapered, conical stem which can improve treatment success in this population. We look at midterm survivorship and outcomes of THA for DDH using the Wagner Cone Prosthesis™. METHODS: We retrospectively analyzed 28 patients (33 hips) with DDH undergoing THA using the Wagner Cone Prosthesis™ between January 2008 and January 2020. Ten, nine, and fourteen included patients were classified as Hartofilakidis A, B, and C, respectively. Survivorship according to Kaplan-Meier analysis was the primary outcome, with re-operation and revision as endpoints. The Oxford hip score (OHS) was used to assess clinical outcome. We used multivariate analysis to determine predictors of poor outcomes. The average follow-up was 4.6 years, with a minimum of two years. RESULTS: Kaplan-Meier survivorship over the 13-year study period was 93.9 ± 4.2% for all-cause revision as an endpoint and 96.9 ± 3.1% for stem revisions only. The overall reoperation rate was 6.1%, with periprosthetic fracture and dislocation being reasons for re-operation. No patients were revised for aseptic loosening, and no patients were revised for subsidence. OHS improved from 19.3 ± 9.6 (4-39) pre-operatively to 37.6 ± 8.4 (19-48) at latest follow-up (p < 0.05). CONCLUSION: In patients with DDH, THA with the Wagner Cone Prosthesis™ demonstrates excellent clinical, radiographic, and patient-reported functional outcomes at midterm follow-up.

The Effect of Femoral Head Size, Neck Length, and Offset on Dislocation Rates of Constrained Acetabular Liners.

BACKGROUND: Constrained acetabular liners (CALs) are used in both primary and revision total hip arthroplasty in cases where stability and abductor deficiency are of concern. The efficacy of CALs has been shown to be design dependent. There is clear evidence that the use of small head sizes and shorter offset in unconstrained total hip arthroplasty is associated with higher rates of dislocation. To our knowledge, no such study has assessed the effect of femoral head size, neck length, and offset for CALs. METHODS: We performed a retrospective study assessing the outcomes of CALs with minimum 2-year follow-up. A Kaplan-Meier survivorship analysis was conducted for all patients and for patients revised for instability. A binomial regression analysis was performed to assess for variables significantly associated with CAL failure. RESULTS: A total of 285 CALs in 281 patients were identified with a mean follow-up of 5.7 years. Ten-year Kaplan-Meier survival analyses were as follows: all indication 91.9% vs instability 85.5% (P = .15). Increasing neck length was associated with lower rates of failure (odds ratio, 0.81; P = .042). Femoral head size, offset, and abductor reconstruction were not significantly associated with CAL failure. CONCLUSION: Larger head size has not been demonstrated to lead to lower failure in CALs. Increasing neck length was associated with lower failure rate. Surgeons should be cautious when attempting to ream to larger acetabular shell sizes for the purpose of using larger heads with CALs. Increasing neck length may instead be targeted intraoperatively.

Midterm Outcomes After Reconstruction of Superolateral Acetabular Defects Using Flying Buttress Porous Tantalum Augments During Revision Total Hip Arthroplasty.

BACKGROUND: Porous tantalum augments are versatile tools in reconstructing complex acetabular defects during revision total hip arthroplasty (THA). This study examines the clinical and radiographic outcomes of porous tantalum augments placed in the type I (flying buttress) configuration at two to 17-year follow-up in the largest cohort to-date in the literature. METHODS: We retrospectively analyzed 59 consecutive revision THAs involving the use of flying buttress augments between 2003 and 2018. The mean patient age and follow-up duration were 63.9 ± 11.6 years (range, 35-87) and 8 years (range, 2-17), respectively. The Oxford hip score was used to assess clinical outcome. The modified Moore classification was used to assess acetabular augment and shell osseointegration. Kaplan-Meier survival analysis with 95% confidence interval (CI) was used to assess implant survivorship. RESULTS: The mean Oxford hip score improved from 15.9 ± 6.2 preoperatively to 35.0 ± 6.5 at a mean follow-up of eight years (P < .0001). Radiographic assessment using the modified Moore classification demonstrated five signs of osseointegration in 49 hips (83.1%), four signs in six hips (10.2%), three signs in one hip (1.7%), and one sign in one hip (1.7%). Kaplan-Meier analysis demonstrated ten-year survivorship of 88.9% (95% CI 74.4-95.4) with all-cause revision as end point and 94.3% (95% CI 83.1-98.2) with revision for acetabular aseptic loosening as end point. CONCLUSION: Treatment of superolateral acetabular defects during revision THA using porous tantalum augments placed in the type I (flying buttress) configuration provides excellent implant survivorship and favorable clinical outcomes at mid-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV.

Intraoperative measurement of acetabular component position using imageless navigation during revision total hip arthroplasty.

BACKGROUND: Acetabular component malposition is a major cause of dislocation following total hip arthroplasty (THA). Intellijoint HIP is an imageless navigation tool that has been shown to provide accurate intraoperative measurement of cup position during primary THA without substantially increasing operative time. However, its accuracy in revision THA has not been evaluated. This study therefore aims to assess the accuracy of Intellijoint HIP in measuring cup inclination and anteversion in comparison with computed tomography (CT) during revision THA. METHODS: Intellijoint HIP was used to measure the position of the preexisting cup in 53 consecutive patients undergoing revision THA between December 2018 and February 2020. Two authors blinded to the intraoperative navigation measurements also independently measured cup position using preoperative CT according to Murray's radiographic definitions. Pearson correlation coefficients with 95% confidence intervals (CIs), paired t tests and Bland-Altman plots were used to assess agreement between navigation- and CT-measured cup position. Statistical analysis was performed using GraphPad Prism, with p values less than 0.05 indicating statistical significance. RESULTS: There was excellent agreement between navigation and CT measurements for both cup inclination (r = 0.89, 95% CI 0.81-0.93) and anteversion (r = 0.93, 95% CI 0.88-0.96), with the mean absolute difference being 5.2º (standard deviation [SD] 4.0º) for inclination and 4.8º (SD 5.4º) for anteversion. The navigation measurement was within 10º of the radiographic measurement in 47 of 53 (88.7%) cases for inclination and 46 of 53 (86.8%) cases for anteversion. CONCLUSION: Imageless navigation demonstrated excellent correlation and agreement with CT measurements for both inclination and anteversion over a wide range of acetabular component positions.

Total hip arthroplasty in patients with fibrous dysplasia: a modern update.

Background: Fibrous dysplasia (FD) results from an abnormality in lamellar bone formation and most frequently involves the proximal femur. This can lead to the development of osteoarthritis requiring total hip arthroplasty (THA). Such cases are challenging, and there is a lack of information guiding best management. As such, we devised a study assessing the outcomes and complications in patients with FD undergoing THA with modern implant technology, and we outlined our preferred surgical technique. Methods: A search of our institutional arthroplasty database was performed to identify patients who underwent THA for FD between January 2001 and July 2018 at Mount Sinai Hospital in Toronto, Canada. Data regarding implants used and the use of allograft material or metal augments or both were obtained. Complications and revision requirements were noted. Radiographic and clinical leg length discrepancies were assessed. Results: A total of 10 hips in 9 patients who underwent THA for FD were identified. Mean follow-up time was 6.0 years (range 0.5 to 10.3 yr). The majority of patients underwent THA using uncemented femoral and acetabular components with large femoral heads on highly cross-linked polyethylene liners. Most cases (80% of hips) required allograft to the proximal femur. A single complication requiring revision was noted. In 90% of hip surgeries, the patient required transfusion of packed red blood cells. Mean radiographic and clinical leg length discrepancies were 0.9 cm (range -2.4 to 2.4 cm) and 0.9 cm (range -4 to 0 cm), respectively. Conclusion: Contrary to previous reports, low complication and revision rates were observed with cementless components and routine use of allograft material. The challenging nature of such cases warrants use of an experienced arthroplasty treatment team.

Contexte: La dysplasie fibreuse (DF) découle d'une anomalie de la formation de l'os lamellaire et affecte le plus souvent le fémur proximal. Elle peut aussi aboutir à l'arthrose qui nécessitera une arthroplastie totale de la hanche (ATH). Or, ces cas sont complexes car on manque d'information sur la meilleure façon de les traiter. Nous avons donc conçu une étude afin d'évaluer l'issue et les complications chez les patients atteints de DF qui subissent une ATH au moyen de techniques d'implants modernes, et nous indiquons la technique chirurgicale que nous privilégions. Méthodes: Nous avons interrogé la base de données de notre établissement sur les arthroplasties pour recenser les patients ayant subi une ATH en raison de la DF entre janvier 2001 et juillet 2018 à l'Hôpital du Mont-Sinaï de Toronto, au Canada. Nous avons obtenu les données sur les implants utilisés et le recours à du matériel de comblement à base d'allogreffes ou de métal ou les deux. Nous avons consigné les complications et les cas où une révision a été nécessaire. Nous avons évalué les inégalités de longueur des membres inférieurs aux plans clinique et radiographique. Résultats: En tout, 10 hanches chez 9 patients ont fait l'objet d'une ATH en raison de la DF. Le suivi moyen a duré 6,0 ans (de 0,5 à 10,3 ans). La majorité des patients ont subi une ATH avec des prothèses à composants fémoraux et acétabulaires non cimentés dotées de têtes fémorales volumineuses, sur des revêtements de polyéthylène hautement réticulé. La plupart des cas (80 % des hanches) ont nécessité une allogreffe au fémur proximal. Une seule complication nécessitant une révision a été notée. Dans 90 % des chirurgies de la hanche, les patients ont eu besoin de transfusions de culots globulaires. Les inégalités cliniques et radiographiques moyennes de la longueur des membres inférieurs ont été de 0,9 cm (entre ­2,4 et 2,4 cm) et de 0,9 cm (de ­4 à 0 cm), respectivement. Conclusion: Contrairement à de précédents rapports, les taux de complications et de révisions observés ont été faibles avec les composants non cimentés et l'utilisation de routine d'allogreffes. La nature complexe de ces cas justifie que l'on fasse appel à une équipe chevronnée pour l'arthroplastie.

Impact of Hip Antibiotic Spacer Dislocation on Final Implant Position and Outcomes.

BACKGROUND: Dislocation of dynamic antibiotic hip spacers during the treatment of periprosthetic joint infection is a well-described complication. Unfortunately, the repercussions of such events after reimplantation of the definitive prosthesis remain largely unknown. As such, we devised a study comparing the perioperative and postoperative outcomes of patients having undergone reimplantation with and without spacer dislocation. METHODS: A search of our institutional database was performed. Two retrospective cohorts were created: dislocated and nondislocated hip spacers. The radiographic and clinical outcomes for each cohort were collected. RESULTS: The two retrospective cohorts contained 24 patients for the dislocated group and 66 for the nondislocated group. Continuous variables noted to be significantly different between the dislocated and nondislocated groups were as follows: clinical leg-length discrepancy (1.35 cm vs 0.41 cm, P = .027), acetabular center of rotation (1.34 cm vs 0.60 cm, P = .011), total packed red blood cell transfusions (4.05 vs 2.37, P = .019), operative time (177.4 min vs 147.3 min, P = .002), and hospital length of stay (7.79 days vs 5.89 days, P = .018). Categorical variables noted to be significantly different were requirement for complex acetabular reconstruction (58.3% vs 13.7%, P < .001), requirement of constrained liners (62.5% vs 37.3%, P = .040), and dislocation after second stage (20.8% vs 6.1%, P = .039). CONCLUSION: Dislocation of dynamic hip spacers leads to inferior clinical results and perioperative outcomes after reimplantation of the definitive prosthesis. Additionally, complex acetabular reconstruction is often required. As such, every effort should be made to prevent hip spacer dislocation.

Does Trochanteric Osteotomy Length Affect the Amount of Proximal Trochanteric Migration During Revision Total Hip Arthroplasty?

BACKGROUND: Nonunion and proximal trochanteric migration is a known complication of trochanteric osteotomy. This study examines the effect of osteotomy length on proximal greater trochanter (GT) migration. METHODS: We analyzed 113 modified trochanteric slide osteotomies and 73 extended trochanteric osteotomies performed between 2008 and 2016. All osteotomies were fixed using cerclage wires and had minimum 6-month radiographic follow-up. Spearman correlations were used to assess association between osteotomy length and GT migration distance. Chi-squared test and logistic regression were used to assess association between patient and surgical factors and GT migration >1 cm. Receiver operating characteristic curves were constructed to determine the optimal cutoff osteotomy length for predicting GT migration >1cm. RESULTS: Mean osteotomy length was 6.1 cm (range 3-12) for modified trochanteric slide osteotomies and 14.8 cm (range 8-23) for extended trochanteric osteotomies. Osteotomy length was negatively correlated (r = -0.340, P < .001) with GT migration distance. Longer osteotomy length was protective against GT migration >1 cm (odds ratio 0.67, P = .002). Receiver operating characteristic curve analysis demonstrated an optimal cutoff osteotomy length of 9.8 cm for predicting GT migration >1 cm (sensitivity 0.971, specificity 0.461). Among osteotomies <10 cm, those fixed using at least one distal wire below the lesser trochanter and vastus ridge demonstrated less mean GT migration (3.86 vs 7.12 mm, P = .009) and higher mean union rate (68.8% vs 31.2%, P < .001). CONCLUSION: Osteotomies shorter than 10 cm are at higher risk of developing proximal GT migration >1 cm. A distal cerclage wire below the lesser trochanter and vastus ridge may help decrease the amount of GT migration. LEVEL OF EVIDENCE: Prognostic Level IV.

Long-term outcomes of total hip arthroplasty in patients younger than 55 years: a systematic review of the contemporary literature

Background: Total hip arthroplasty (THA) is increasingly performed in younger patients despite the lack of comprehensive assessment of long-term outcomes. We systematically reviewed the contemporary literature to assess the 1) indications, 2) implant selection and long-term survivorship, 3) complication and reoperation rates and 4) radiographic and functional outcomes of primary THA in patients younger than 55 years. Methods: We searched the Embase and MEDLINE databases for English-language articles published between 2000 and 2018 that reported outcomes of primary THA in patients younger than 55 years with a minimum follow-up duration of 10 years. Results: Thirty-two studies reporting on 3219 THA procedures performed in 2434 patients met our inclusion criteria. The most common preoperative diagnoses were avascular necrosis (1044 [32.4%]), osteoarthritis (870 [27.0%]) and developmental dysplasia of the hip (627 [19.5%]). Modular implants (3001 [93.2%]), cementless fixation (2214 [68.8%]) and metal-on-polyethylene bearings (1792 [55.7%]) were frequently used. The mean 5- and 10-year survival rates were 98.7% and 94.6%, respectively. Data on survival beyond 10 years were heterogeneous, with values of 27%­99.5% at 10­14 years, 59%­84% at 15­19 years, 70%­77% at 20­24 years and 60% at 25­30 years. Rates of dislocation, deep infection and reoperation for any reason were 2.4%, 1.2% and 16.3%, respectively. The mean Harris Hip Score improved from 43.6/100 to 91.0/100. Conclusion: Total hip arthroplasty in patients younger than 55 years provides reliable outcomes at up to 10 years. Future studies should evaluate the outcomes of THA in this population at 15­20 years' follow-up.

Contexte: On effectue de plus en plus d'arthroplasties totales de la hanche (ATH) chez des patients qui ne sont pas âgés, malgré l'absence d'évaluation exhaustive des issues à long terme. Nous avons procédé à une revue systématique de la littérature récente pour analyser 1) les indications, 2) la sélection des implants et la survie à long terme, 3) les taux de complications et de réintervention, et 4) les résultats radiographiques et fonctionnels des ATH primaires chez les patients de moins de 55 ans. Méthodes: Nous avons interrogé les bases de données Embase et MEDLINE pour recenser les articles de langue anglaise publiés entre 2000 et 2018 qui faisaient état des issues d'ATH primaires chez des patients de moins de 55 ans suivis pendant au moins 10 ans. Résultats: Trente-deux études portant sur 3219 ATH effectuées chez 2434 patients répondaient à nos critères d'inclusion. Les diagnostics préopératoires les plus fréquents étaient la nécrose avasculaire (1044 [32,4 %]), l'arthrose (870 [27,0 %]) et la dysplasie développementale de la hanche (627 [19,5 %]). Les implants modulaires (3001 [93,2 %]), la fixation non cimentée (2214 [68,8 %]) et le couple métal­polyéthylène (1792 [55,7 %]) ont été fréquemment utilisés. Les taux de survie moyens à 5 et à 10 ans étaient de 98,7 % et de 94,6 %, respectivement. Les données sur la survie au-delà de 10 ans étaient hétérogènes, allant de 27 % à 99,5 % après 10 à 14 ans, de 59 % à 84 % après 15 à 19 ans, de 70 % à 77 % après 20 à 24 ans et de 60 % après 25 à 30 ans. Les taux de dislocation, d'infection profonde et de réintervention, toutes causes confondues, étaient de 2,4 %, de 1,2 % et de 16,3 %, respectivement. Le score de Harris moyen s'est amélioré, passant de 43,6/100 à 91,0/100. Conclusion: L'arthroplastie totale de la hanche chez les patients de moins de 55 ans donne des résultats fiables pour les 10 premières années après l'intervention. Les prochaines études devraient évaluer les issues de l'arthroplastie de la hanche dans cette population après 15 à 20 ans de suivi.

Fresh Osteochondral Allograft Transplantation for Treatment of Large Cartilage Defects of the Femoral Head: A Minimum Two-Year Follow-Up Study of Twenty-Two Patients.

BACKGROUND: Controversy remains over the surgical management of large osteochondral lesions of the femoral head in young, active patients. The purpose of this study is to assess midterm clinical and radiographic outcomes after fresh osteochondral allograft transplantation (OAT) for large femoral head lesions at minimum 2-year follow-up. METHODS: A retrospective review of prospectively collected data was performed for 22 patients under the age of 50 years with defined femoral head osteochondral lesions who underwent fresh OAT between 2008 and 2015. Patients were assessed clinically using the modified Harris Hip Score (mHHS) preoperatively and at each follow-up visit. Postoperative radiographs were evaluated for graft integrity and Kellgren & Lawrence Grade for osteoarthritis severity. Complications and reoperation were assessed by chart review. Kaplan-Meier survivorship analyses with 95% confidence intervals were performed for the end point of conversion to total hip arthroplasty. RESULTS: At a mean follow-up of 68.8 months (26-113), the mean mHHS improved significantly (P < .001) from 48.9 (19-84) to 77.4 (35-98). Sixteen of 22 patients (72.7%) had an mHHS ≥70 at the latest follow-up. Arthritic progression, as indicated by an increase in the Kellgren & Lawrence Grade, occurred in 4 of 22 hips (18.2%). Five patients (22.7%) underwent conversion to total hip arthroplasty. Graft survivorship was 86.4 ± 7.3% at 2 years, 78.5 ± 10.0% at 5 years, and 67.3 ± 13.5% at 9 years. CONCLUSION: Fresh OAT may be a viable treatment option for osteochondral defects of the femoral head in young, active patients with minimal preexisting joint deformity.

Revision Total Hip Arthroplasty for Fractured Ceramic Bearings: A Review of Best Practices for Revision Cases.

BACKGROUND: Total hip arthroplasty revision for a fractured ceramic bearing is rare but offers unique challenges. The purpose of this review was to provide a summary of existing literature on fractured ceramic bearings. METHODS: Two authors performed a literature search of the MEDLINE OVID and PubMed databases with the following search terms: ceramic, fracture, total hip arthroplasty, and revision. RESULTS: The search identified 228 articles of which 199 were selected for review. CONCLUSIONS: It is mandatory to perform a complete synovectomy and thorough debridement of the fractured ceramic fragments. A well-fixed acetabular component should be removed if either the locking mechanism is damaged or the component is malpositioned. If the femoral stem taper is damaged, the femoral stem should be removed. However, if minimal damage is present, the femoral stem may be retained and revised using a fourth generation ceramic head with a titanium sleeve. Metal bearings should be avoided and revision with ceramic bearings should be performed whenever possible.

Promising Mid-term Results With a Cup-cage Construct for Large Acetabular Defects and Pelvic Discontinuity.

BACKGROUND: Restoring normal anatomy and achieving stable fixation of the acetabular component can be especially challenging when the surgeon must deal with severe acetabular defects and/or pelvic discontinuity. The cup-cage (CC) construct, where an ilioischial cage is cemented within a biologically fixed porous metal cup, has emerged as an excellent option to treat such challenges. QUESTIONS/PURPOSES: We sought to determine (1) mid-term Kaplan-Meier survival; (2) clinical outcomes based on Merle d'Aubigné-Postel scores; (3) radiological outcomes based primarily on construct migration; and (4) the complication rate for a series of 67 CC procedures performed at our institution. METHODS: All hip revision procedures between January 2003 and March 2012 where a CC was used (with the exception of tumor cases or acute fracture; four total cases) that had a minimum 2-year followup and that had been seen within the last 2 years were included in this retrospective review. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven CC procedures with an average followup of 74 months (range, 24-135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Postoperative clinical and radiological evaluation was done annually. Merle d'Aubigné-Postel scores were recorded and all radiographs were compared with the 6-week postoperative radiographs to evaluate for radiographic loosening or migration. Failure was defined as revision surgery for any cause, including infection. RESULTS: The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval [CI], 83.1-97.4), and the 10-year survival rate was 85% (95% CI, 67.2-93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 preoperatively to 13 postoperatively (p < 0.001). Four CC had nonprogressive radiological migration of the ischial flange and they remain stable. CONCLUSIONS: We believe that the CC construct is a suitable choice to treat chronic pelvic discontinuity; it also remains a reliable option for the treatment of severe acetabular bone defects if stable fixation cannot be obtained through the use of a trabecular metal cup with or without augments. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Outcome of Revision Total Hip Arthroplasty in Management of Failed Metal-on-Metal Hip Arthroplasty.

BACKGROUND: This is a retrospective review of the functional outcomes and complications of revision total hip arthroplasty (THA) of failed metal-on-metal (MoM) hip arthroplasty. METHODS: A total of 20 revision THAs were performed in 19 patients. Of them, 2 cases were failed hip resurfacing, and 18 cases were failed (MoM) THA. The mean age at revision (THA) was 59.35 years (standard deviation [SD] 9.83). RESULTS: The mean follow-up was 45 months (SD 13.98). The indications of revision were aseptic loosening of acetabular component without adverse local tissue reaction (ALTR; 10 hips), aseptic loosening of the acetabular and femoral components without ALTR (1 hip), painful hip associated with ALTR (6 hips), iliopsoas impingement associated with a large-diameter femoral head or malpositioned acetabular component (3 hips). The acetabular components were revised in 18 hips using Trabecular Metal Modular cups. The femoral components were revised in 3 hips. A constrained acetabular liner was used in 5 hips. The Harris hip score significantly improved from 48.4 (SD 12.98) to 83.25 (SD 10.08). There were 2 complications (1 foot drop and 1 superficial infection) and 1 failure (recurrent dislocation) that required revision to a constrained liner. CONCLUSION: Early results of revision THA of failed MoM hip arthroplasty showed improvement in pain and functional outcome. No case of failed bone ingrowth was noted with the use of Trabecular Metal Modular cups. Extensive soft tissue and abductor muscles dysfunctions were common. A constrained acetabular component with repair of the hip abductors might be beneficial.

The Use of a Supra-Acetabular Antibiotic-Loaded Cement Shelf to Improve Hip Stability in First-Stage Infected Total Hip Arthroplasty.

BACKGROUND: Antibiotic-loaded cement spacers in first-stage revision total hip arthroplasty (THA) for managing infection are associated with high dislocation and fracture rates. The aim of this study was to report the use of an antibiotic-loaded cemented supra-acetabular roof augmentation to reinforce hip stability after cement spacer insertion for first-stage total hip revision in the treatment of infected THA. METHODS: We retrospectively reviewed a consecutive series of 50 THAs involving 47 patients with an infected hip requiring staged revisions of THA. We documented dislocation, reinfection, and time for revision and outcome. RESULTS: There were no cases of hip dislocation, cement fractures, or any other technical complications associated with the use of the roof augmentation lip. Thirteen cases (26%) had a cemented spacer for longer than 120 days. Seven (14%) cases had recurrent infection after staged revision THA. CONCLUSION: The antibiotic-loaded cemented supra-acetabular roof augment improved femoral head spacer coverage for patients requiring a staged revision THA for infection.

Closed suction drainage has no benefits in revision total hip arthroplasty: a randomized controlled trial.

PURPOSE: Several studies have failed to show significant benefits of closed suction drainage (CSD) in routine primary total hip arthroplasty (THA). However, blood loss, haematoma formation and wound complications are generally much greater in revision THA as compared to primary THA. The purpose of this study was to determine if CSD is beneficial for revision THA patients. METHODS: We conducted a prospective, randomized, controlled trial at our institution between July 2013 and July 2014. Eighty-eight patients undergoing revision THA were enrolled and randomly assigned to receive a CSD (n = 44) or to not receive a CSD (n = 44). All first-stage revision surgeries for infection were excluded. Primary outcomes were haemoglobin loss and number of patients transfused. Secondary outcomes included functional outcome evaluated with Harris hip score (HHS), pain evaluated with visual analogue scale (VAS), and length of hospital stay. RESULTS: There were significantly more patients in the CSD group that required blood transfusions (20/44 as compared to 11/44, p = 0.04). Patients in the no CSD group were discharged earlier than patients in the CSD group (4.3 days as compared to 5.4 days, p = 0.002). No statistical significant difference was found in the HHS or pain VAS between the groups. CONCLUSIONS: This study did not demonstrate any benefit with the use of CSD for revision THA with regard to wound related complications, infection or early functional outcome. Post-operative blood loss, transfusion rate, and length of hospital stay may be higher with CSD.