Short-Term Results of Osteochondral Autologous Transfer and Femoral Neck Osteochondroplasty for the Treatment of Osteochondral Lesions of the Femoral Head and Concomitant Femoroacetabular Impingement Syndrome: A Case Series.

This study aimed to analyse the initial results of five patients with symptomatic osteochondral lesions (OCL) and femoroacetabular impingement (FAI) who were treated successfully with osteochondral autologous transfer (OAT) and femoral neck osteochondroplasty (OCP) through surgical dislocation of the hip. Five patients with FAI and OCL of the femoral head who underwent surgery between 2015-2018 were studied retrospectively. All patients had a grade IV OCL, and the median defect size was 2 cm2 (interquartile range [IQR], 2-2). At the final follow-up, the modified Harris hip score showed a median value of 94 (IQR, 91-95) (P=0.04). Pain evaluation using the visual analogue scale showed a median value of 1 (IQR, 1-2) (P=0.04). Adequate graft union and healthy formation of the chondral surface were observed by magnetic resonance imaging. Although the procedure is demanding, the combination of OAT and femoral neck OCP appears to be an effective alternative in young patients.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

Revision total hip arthroplasty in the setting of extensive femoral bone loss poses a considerable challenge to the adult reconstructive surgeon. When the proximal femoral bone stock is deficient or absent, there are few options for reconstruction. In such cases, treatment options include distal cementless fixation (either modular or nonmodular), impaction bone grafting (IBG), a megaprosthesis, or even an allograft-prosthesis composite. Each of these procedures has advantages and disadvantages related to bone preservation, surgical timing, and complexity (depending on the learning curve). For its capacity of restoring bone stock, we have been utilizing the IBG technique at our center since August 1987. The aim of the present article was to describe a step-by-step femoral IBG procedure for severe proximal femoral circumferential bone loss, highlighting its current indications and contraindications. Description: The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. Alternatives: There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. Rationale: The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. Expected Outcomes: We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. Important Tips: This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. Acronyms & Abbreviations: PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

Double-trabecular metal cup technique for the management of Paprosky type III defects without pelvic discontinuity.

INTRODUCTION:: Modular reconstruction systems based on trabecular metal (TM) prosthetic components have been increasingly used in the last decade for the management of severe acetabular bone defects. The aim of this study was to assess the clinical and radiographic outcomes of double-cup technique for the management of Paprosky type III defects without pelvic discontinuity. METHODS:: A retrospective review was performed for all patients undergoing acetabular reconstruction with 2 TM cups at a tertiary referral centre between 2010 and 2015. Harris Hip Scores (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at the latest follow-up. Radiographic assessment of the hip centre of rotation (COR) position and leg length discrepancy (LLD) was performed preoperatively and postoperatively. Osteolysis and radiolucencies, loosening of the implants, and heterotopic ossifications were evaluated with the latest follow-up radiographs. RESULTS:: Patients included 5 men and 11 women (16 hips) with an average age of 68 (45-81) years. Acetabular bone defects included 9 Paprosky type IIIB and 7 type IIIA defects. No pelvic discontinuities were registered. The mean follow-up was 34 (24-72) months. HHS and WOMAC scores, LLD and COR position significantly improved after surgery. In only 1 (6.3%) hip a not progressive radiolucent line adjacent the acetabular construct was noted. Heterotopic ossifications were found in 2 (12.5%) hips. No patients underwent acetabular components revision surgery for any reason. CONCLUSION:: The double-cup technique could be considered an effective management of selected Paprosky type III defects without pelvic discontinuity providing excellent clinical and radiographic outcomes in the short term.

Osteoclastogenesis in peripheral blood mononuclear cell cultures of periprosthetic osteolysis patients and the phenotype of T cells localized in periprosthetic tissues.

Arthroplasty is a very successful medical procedure. Failures depend on aseptic loosening caused by periprosthetic osteolysis, where T cells have a contradictory role. We analyzed osteoclastogenesis in peripheral blood mononuclear cell (PBMC) cultures of periprosthetic osteolysis patients and the phenotype of T cells localized in periprosthetic tissues. We enrolled 45 subjects with periprosthetic osteolysis (15), stable prosthesis (15) and healthy controls (15). We performed PBMC cultures to study osteoclastogenesis. Osteoclasts and T cell phenotype were examined by immunohistochemistry, immunofluorescence and flow citometry. Periprosthetic osteolysis patients showed spontaneous osteoclastogenesis, which was inhibited by RANK-Fc and T cell depletion. In periprosthetic osteolysis patients' PBMC cultures, CD4 and CD8 T cells increased and CD8 T cells did not express CD25. In periprosthetic tissues T cells were close to osteoclasts, suggesting their interaction. Local CD8 T cells showed a regulatory phenotype, expressing CD25 and FoxP3, while CD4 T cells did not express activation markers. Our data suggest that, in an early stage of periprosthetic osteolysis, T cells may promote osteoclastogenesis, whereas subsequently osteoclasts activate FoxP3/CD8 T cells, which inhibit CD4 effector T cells. This mechanism may explain the previous finding of non-active T cells in periprosthetic tissues.