RESUMEN
Antibiotic-loaded cement spacers in first-stage revision hip arthroplasty for infection are associated with a high dislocation and fracture rate. This technical note describes a novel surgical technique, utilizing screws and cement, improving acetabular coverage and reducing the risk of mechanical failure. Fifteen infected hip prostheses underwent removal, cement acetabular augmentation and insertion of a femoral cement spacer. Eleven hips had successful infection eradication and subsequently underwent a second stage revision procedure a mean duration of 15 weeks (9-48) after the first stage. No dislocations or fractures of the cement spacers were observed. This technique affords the potential to reduce the duration of time cement spacers remaining in situ, provides enhanced mechanical stability and improved antibiotic elution through cement-on-cement articulation.
Asunto(s)
Acetábulo/cirugía , Antibacterianos/administración & dosificación , Artroplastia de Reemplazo de Cadera/métodos , Articulación de la Cadera/cirugía , Prótesis de Cadera , Infecciones Relacionadas con Prótesis/cirugía , Cementos para Huesos , Cementación , Humanos , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , ReoperaciónRESUMEN
AIMS: The aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function. PATIENTS AND METHODS: We identified 60 patients (16 women, 44 men) who underwent unipolar femoral condylar FOCA with concomitant realignment between 1972 and 2012. The mean age of the patients was 28.9 years (10 to 62) and the mean follow-up was 11.4 years (2 to 35). Failure was defined as conversion to total knee arthroplasty, revision allograft, or graft removal. Clinical outcome was evaluated using the modified Hospital for Special Surgery (mHSS) score. RESULTS: A total of 14 grafts (23.3%) failed at a mean of 8.6 years (1.4 to 20.1). Graft survivorship was 87.3% (95% confidence interval (CI) 79.0 to 96.6), 85.0% (95% CI 75.8 to 95.3), 74.8% (95% CI 62.2 to 90.0), 65.2% (95% CI 49.9 to 85.2), and 59.8% (95% CI 43.5 to 82.1) at five, ten, 15, 20, and 25 years, respectively. A total of 23 patients (38.3%) developed complications, and 26 (43.3%) had a further operation. Persistent postoperative malalignment occurred more frequently in failed grafts (28.6% vs 4.3%; p = 0.023), and was a risk factor for graft failure (hazard ratio 6.55; 95% CI 1.61 27.71; p = 0.009). The mean mHSS score improved from 74.1 (40 to 91) preoperatively to 89.0 (66 to 100) at final follow-up (p < 0.001). CONCLUSION: Femoral condylar FOCA with concomitant realignment osteotomy provides excellent long-term graft survival and reliable functional improvement. Persistent malalignment may increase the risk for graft failure.
Asunto(s)
Desviación Ósea/cirugía , Trasplante Óseo/métodos , Cartílago Articular/cirugía , Traumatismos de la Rodilla/cirugía , Articulación de la Rodilla/cirugía , Osteotomía/métodos , Adolescente , Adulto , Desviación Ósea/diagnóstico por imagen , Trasplante Óseo/efectos adversos , Niño , Femenino , Fémur/trasplante , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Traumatismos de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Osteotomía/efectos adversos , Complicaciones Posoperatorias , Radiografía , Reoperación/métodos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Fresh osteochondral allograft transplantation has been an effective treatment option with promising long-term clinical outcomes for focal posttraumatic defects in the knee for young, active individuals. We examined histologic features of 35 fresh osteochondral allograft specimens retrieved at the time of subsequent graft revision, osteotomy, or TKA. Graft survival time ranged from 1 to 25 years based on their time to reoperation. Histologic features of early graft failures were lack of chondrocyte viability and loss of matrix cationic staining. Histologic features of late graft failures were fracture through the graft, active and incomplete remodeling of the graft bone by the host bone, and resorption of the graft tissue by synovial inflammatory activity at graft edges. Histologic features associated with long-term allograft survival included viable chondrocytes, functional preservation of matrix, and complete replacement of the graft bone with the host bone. Given chondrocyte viability, long-term allograft survival depends on graft stability by rigid fixation of host bone to graft bone. With the stable osseous graft base, the hyaline cartilage portion of the allograft can survive and function for 25 years or more.
Asunto(s)
Trasplante Óseo , Condrocitos/trasplante , Adolescente , Adulto , Anciano , Cartílago Articular/citología , Cartílago Articular/patología , Supervivencia Celular , Condrocitos/fisiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Trasplante Homólogo , Resultado del TratamientoRESUMEN
AIMS: It may not be possible to undertake revision total hip arthroplasty (THA) in the presence of massive loss of acetabular bone stock using standard cementless hemispherical acetabular components and metal augments, as satisfactory stability cannot always be achieved. We aimed to study the outcome using a reconstruction cage and a porous metal augment in these patients. PATIENTS AND METHODS: A total of 22 acetabular revisions in 19 patients were performed using a combination of a reconstruction cage and porous metal augments. The augments were used in place of structural allografts. The mean age of the patients at the time of surgery was 70 years (27 to 85) and the mean follow-up was 39 months (27 to 58). The mean number of previous THAs was 1.9 (1 to 3). All patients had segmental defects involving more than 50% of the acetabulum and seven hips had an associated pelvic discontinuity. RESULTS: Three failures were observed in two hips, both of which had undergone a previous resection of a tumour affecting the acetabulum. Other complications included a late arterial injury, a sciatic nerve palsy, a dislocation treated with a femoral revision, a deep infection treated with irrigation and debridement and a fracture of the greater trochanter treated conservatively. The mean Oxford Hip Score significantly increased from 13.9 (2 to 23) to 28.7 (13 to 38) (p < 0.00001). The mean vertical distance between the centre of rotation of the hip and its normal location decreased from 30 mm to 10 mm. CONCLUSIONS: Acceptable early survivorship can be achieved using this novel technique, but it may be unsuitable for use in patients who have previously undergone the resection of a tumour involving the acetabulum. Cite this article: Bone Joint J 2017;99-B:607-13.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/métodos , Trasplante Óseo/métodos , Acetábulo/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/instrumentación , Femenino , Prótesis de Cadera , Humanos , Fijadores Internos , Estimación de Kaplan-Meier , Masculino , Metales , Persona de Mediana Edad , Osteotomía/métodos , Porosidad , Diseño de Prótesis , Radiografía , Reoperación/instrumentación , Reoperación/métodos , Estudios RetrospectivosRESUMEN
An uncemented hemispherical acetabular component is the mainstay of acetabular revision and gives excellent long-term results. Occasionally, the degree of acetabular bone loss means that a hemispherical component will be unstable when sited in the correct anatomical location or there is minimal bleeding host bone left for biological fixation. On these occasions an alternative method of reconstruction has to be used. A major column structural allograft has been shown to restore the deficient bone stock to some degree, but it needs to be off-loaded with a reconstruction cage to prevent collapse of the graft. The use of porous metal augments is a promising method of overcoming some of the problems associated with structural allograft. If the defect is large, the augment needs to be protected by a cage to allow ingrowth to occur. Cup-cage reconstruction is an effective method of treating chronic pelvic discontinuity and large contained or uncontained bone defects. This paper presents the indications, surgical techniques and outcomes of various methods which use acetabular reconstruction cages for revision total hip arthroplasty.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/instrumentación , Artroplastia de Reemplazo de Cadera/métodos , Enfermedades Óseas/cirugía , Trasplante Óseo , Humanos , Reoperación , Índice de Severidad de la EnfermedadRESUMEN
Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis. The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.
Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Luxación Congénita de la Cadera/cirugía , Adulto , Anciano , Femenino , Articulación de la Cadera/patología , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Falla de Prótesis , Reoperación/métodos , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
This study reports the clinical outcome of reconstruction of deficient abductor muscles following revision total hip arthroplasty (THA), using a fresh-frozen allograft of the extensor mechanism of the knee. A retrospective analysis was conducted of 11 consecutive patients with a severe limp because of abductor deficiency which was confirmed on MRI scans. The mean age of the patients (three men and eight women) was 66.7 years (52 to 84), with a mean follow-up of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild limp, and two had a persistent severe limp (p = 0.004). The mean power of the abductors improved on the Medical Research Council scale from 2.15 to 3.8 (p < 0.001). Pre-operatively, all patients required a stick or walking frame; post-operatively, four patients were able to walk without an aid. Overall, nine patients had severe or moderate pain pre-operatively; ten patients had no or mild pain post-operatively. At final review, the Harris hip score was good in five patients, fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively effective in the treatment of chronic abductor deficiency of the hip after THA when techniques such as local tissue transfer are not possible. Longer-term follow-up is necessary before the technique can be broadly applied.
Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Músculo Esquelético/trasplante , Procedimientos de Cirugía Plástica/métodos , Complicaciones Posoperatorias/cirugía , Anciano , Anciano de 80 o más Años , Aloinjertos , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio , Calidad de Vida , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The use of ilioischial cage reconstruction for pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer, Warsaw, Indiana) cup-cage technique in our institution, due to the unsatisfactory outcome of using a cage alone in this situation. We report the outcome of 26 pelvic discontinuities in 24 patients (20 women and four men, mean age 65 years (44 to 84)) treated by the cup-cage technique at a mean follow-up of 82 months (12 to 113) and compared them with a series of 19 pelvic discontinuities in 19 patients (18 women and one man, mean age 70 years (42 to 86)) treated with a cage at a mean follow-up of 69 months (1 to 170). The clinical and radiological outcomes as well as the survivorship of the groups were compared. In all, four of the cup-cage group (15%) and 13 (68%) of the cage group failed due to septic or aseptic loosening. The seven-year survivorship was 87.2% (95% confidence interval (CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84) for the cage-alone group (p = 0.009). There were four major complications in the cup-cage group and nine in the cage group. Radiological union of the discontinuity was found in all successful cases in the cup-cage group and three of the successful cage cases. Three hips in the cup-cage group developed early radiological migration of the components, which stabilised with a successful outcome. Cup-cage reconstruction is a reliable technique for treating pelvic discontinuity in mid-term follow-up and is preferred to ilioischial cage reconstruction. If the continuity of the bone graft at the discontinuity site is not disrupted, early migration of the components does not necessarily result in failure.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/métodos , Trasplante Óseo/métodos , Prótesis de Cadera , Huesos Pélvicos/cirugía , Procedimientos de Cirugía Plástica/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
The purpose of this study was to identify factors that predict implant cut-out after cephalomedullary nailing of intertrochanteric and subtrochanteric hip fractures, and to test the significance of calcar referenced tip-apex distance (CalTAD) as a predictor for cut-out. We retrospectively reviewed 170 consecutive fractures that had undergone cephalomedullary nailing. Of these, 77 met the inclusion criteria of a non-pathological fracture with a minimum of 80 days radiological follow-up (mean 408 days; 81 days to 4.9 years). The overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex distance (TAD) (p < 0.001), CalTAD (p = 0.001), cervical angle difference (p = 0.004), and lag screw placement in the anteroposterior (AP) view (Parker's ratio index) (p = 0.003). Non-significant parameters were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507), fracture type (AO classification) (p = 0.381), Singh Osteoporosis Index (p = 0.575), lag screw placement in the lateral view (p = 0.123), and reduction quality (modified Baumgaertner's method) (p = 0.575). In the multivariate analysis, CalTAD was the only significant measurement (p = 0.001). CalTAD had almost perfect inter-observer reliability (interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD is a predictor of cut-out. The finding of CalTAD as the only significant parameter in the multivariate analysis, along with the univariate significance of Parker's ratio index in the AP view, suggest that inferior placement of the lag screw is preferable to reduce the rate of cut-out.
Asunto(s)
Fijación Intramedular de Fracturas/métodos , Fracturas de Cadera/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Clavos Ortopédicos , Tornillos Óseos , Falla de Equipo , Femenino , Fijación Intramedular de Fracturas/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Variaciones Dependientes del Observador , Estudios Retrospectivos , Adulto JovenRESUMEN
Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions. We have assessed the survivorship, functional outcome and complications of this procedure in patients aged < 50 years through a large longitudinal series with consistent treatment algorithms. Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated. Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review. This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.
Asunto(s)
Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Adulto , Factores de Edad , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Falla de Prótesis , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Cartilage defects of the hip cause significant pain and may lead to arthritic changes that necessitate hip replacement. We propose the use of fresh osteochondral allografts as an option for the treatment of such defects in young patients. Here we present the results of fresh osteochondral allografts for cartilage defects in 17 patients in a prospective study. The underlying diagnoses for the cartilage defects were osteochondritis dissecans in eight and avascular necrosis in six. Two had Legg-Calve-Perthes and one a femoral head fracture. Pre-operatively, an MRI was used to determine the size of the cartilage defect and the femoral head diameter. All patients underwent surgical hip dislocation with a trochanteric slide osteotomy for placement of the allograft. The mean age at surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months (3 to 74). The mean Harris hip score was significantly better after surgery (p<0.01) and 13 patients had fair to good outcomes. One patient required a repeat allograft, one patient underwent hip replacement and two patients are awaiting hip replacement. Fresh osteochondral allograft is a reasonable treatment option for hip cartilage defects in young patients.
Asunto(s)
Trasplante Óseo/métodos , Cartílago Articular/cirugía , Osteocondritis Disecante/cirugía , Osteotomía/métodos , Procedimientos de Cirugía Plástica/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aloinjertos , Cartílago Articular/diagnóstico por imagen , Cartílago Articular/patología , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Osteocondritis Disecante/diagnóstico , Estudios Prospectivos , Radiografía , Resultado del Tratamiento , Adulto JovenRESUMEN
We retrospectively reviewed 44 consecutive patients (50 hips) who underwent acetabular re-revision after a failed previous revision that had been performed using structural or morcellised allograft bone, with a cage or ring for uncontained defects. Of the 50 previous revisions, 41 cages and nine rings were used with allografts for 14 minor-column and 36 major-column defects. We routinely assessed the size of the acetabular bone defect at the time of revision and re-revision surgery. This allowed us to assess whether host bone stock was restored. We also assessed the outcome of re-revision surgery in these circumstances by means of radiological characteristics, rates of failure and modes of failure. We subsequently investigated the factors that may affect the potential for the restoration of bone stock and the durability of the re-revision reconstruction using multivariate analysis. At the time of re-revision, there were ten host acetabula with no significant defects, 14 with contained defects, nine with minor-column, seven with major-column defects and ten with pelvic discontinuity. When bone defects at re-revision were compared with those at the previous revision, there was restoration of bone stock in 31 hips, deterioration of bone stock in nine and remained unchanged in ten. This was a significant improvement (p < 0.001). Morselised allografting at the index revision was not associated with the restoration of bone stock. In 17 hips (34%), re-revision was possible using a simple acetabular component without allograft, augments, rings or cages. There were 47 patients with a mean follow-up of 70 months (6 to 146) available for survival analysis. Within this group, the successful cases had a minimum follow-up of two years after re-revision. There were 22 clinical or radiological failures (46.7%), 18 of which were due to aseptic loosening. The five and ten year Kaplan-Meier survival rate was 75% (95% CI, 60 to 86) and 56% (95% CI, 40 to 70) respectively with aseptic loosening as the endpoint. The rate of aseptic loosening was higher for hips with pelvic discontinuity (p = 0.049) and less when the allograft had been in place for longer periods (p = 0.040). The use of a cage or ring over structural allograft bone for massive uncontained defects in acetabular revision can restore host bone stock and facilitate subsequent re-revision surgery to a certain extent.
Asunto(s)
Acetábulo/patología , Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Trasplante Óseo/métodos , Prótesis de Cadera , Procedimientos de Cirugía Plástica/métodos , Aloinjertos , Femenino , Humanos , Masculino , Osteotomía , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: Our purpose was to identify what surgical skills trainees consider important to possess before performing in the operating room and the components of an optimal simulator. METHODS: An online survey composed of 35 questions was completed by 67 orthopedic residents from across Canada. The questions examined the opinions of residents for their perspective on what constitutes an optimal design of an arthroscopic simulator. RESULTS: The average year of residency of the respondents was 3.2, and the average number of arthroscopies assisted on was 66.1 with a range of 0-300. Identification of structures and navigation of the arthroscope were ranked highly in terms of importance for trainee surgeons to possess before performing in the operating room. Higher fidelity simulation models such as cadaveric specimens or the use of synthetic knees were preferred over lower fidelity simulation models such as virtual reality simulators or bench top models. CONCLUSION: The information from trainees can be used in the development of a simulator for medical education as well as program and curriculum design. The report also highlights the importance of the pre-RCT phases leading to the development of the most effective simulation programs.
Asunto(s)
Artroscopía/educación , Competencia Clínica , Simulación por Computador , Curriculum , Internado y Residencia , Ortopedia/educación , Recolección de Datos , Humanos , Médicos , Evaluación de Programas y Proyectos de SaludRESUMEN
Trabecular metal (TM) augments are a relatively new option for reconstructing segmental bone loss during acetabular revision. We studied 34 failed hip replacements in 34 patients that were revised between October 2003 and March 2010 using a TM acetabular shell and one or two augments. The mean age of the patients at the time of surgery was 69.3 years (46 to 86) and the mean follow-up was 64.5 months (27 to 107). In all, 18 patients had a minor column defect, 14 had a major column defect, and two were associated with pelvic discontinuity. The hip centre of rotation was restored in 27 patients (79.4%). The Oxford hip score increased from a mean of 15.4 points (6 to 25) before revision to a mean of 37.7 (29 to 47) at the final follow-up. There were three aseptic loosenings of the construct, two of them in the patients with pelvic discontinuity. One septic loosening also occurred in a patient who had previously had an infected hip replacement. The augments remained stable in two of the failed hips. Whenever there was a loose acetabular component in contact with a stable augment, progressive metal debris shedding was evident on the serial radiographs. Complications included another deep infection treated without revision surgery. Good clinical and radiological results can be expected for bone-deficient acetabula treated by a TM cup and augment, but for pelvic discontinuities this might not be a reliable option.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/métodos , Fosfatos de Calcio/uso terapéutico , Prótesis de Cadera/efectos adversos , Falla de Prótesis/etiología , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Fosfatos de Calcio/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Metales , Persona de Mediana Edad , Diseño de Prótesis , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The conventional method for reconstructing acetabular bone loss at revision surgery includes using structural bone allograft. The disadvantages of this technique promoted the advent of metallic but biocompatible porous implants to fill bone defects enhancing initial and long-term stability of the acetabular component. This paper presents the indications, surgical technique and the outcome of using porous metal acetabular augments for reconstructing acetabular defects.
Asunto(s)
Acetábulo/patología , Acetábulo/cirugía , Trasplante Óseo/métodos , Prótesis de Cadera , Aloinjertos , Materiales Biocompatibles , Remoción de Dispositivos , Humanos , Porosidad , Diseño de Prótesis , Falla de Prótesis , Reoperación , Propiedades de SuperficieRESUMEN
In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant-bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision. A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up. Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/métodos , Trasplante Óseo/métodos , Luxación Congénita de la Cadera/cirugía , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Luxación Congénita de la Cadera/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Ontario/epidemiología , Reoperación/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Trasplante Autólogo , Resultado del TratamientoRESUMEN
Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons' competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.
Asunto(s)
Artroplastia de Reemplazo/educación , Competencia Clínica , Educación de Postgrado en Medicina/métodos , Médicos/normas , Humanos , Reproducibilidad de los ResultadosAsunto(s)
Artroplastia de Reemplazo de Rodilla , Neoplasias Óseas/cirugía , Trasplante Óseo/fisiología , Fémur/cirugía , Cartílago Hialino/anatomía & histología , Cartílago/citología , Cartílago/diagnóstico por imagen , Femenino , Fémur/citología , Fémur/diagnóstico por imagen , Humanos , Microscopía Electrónica , Persona de Mediana Edad , Radiografía , Trasplante Homólogo , UltrasonografíaRESUMEN
Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in three hips. Mean follow up was five years (two to 15). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in seven (39%) hips, in one case resulting in joint ankylosis. No hips dislocated. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function.
Asunto(s)
Artritis Infecciosa/cirugía , Artrodesis , Artroplastia de Reemplazo de Cadera , Luxación Congénita de la Cadera/cirugía , Fracturas de Cadera/cirugía , Adulto , Anciano , Artroplastia de Reemplazo de Cadera/instrumentación , Artroplastia de Reemplazo de Cadera/métodos , Femenino , Estudios de Seguimiento , Prótesis de Cadera , Humanos , Masculino , Persona de Mediana Edad , Osificación Heterotópica/diagnóstico por imagen , Osificación Heterotópica/epidemiología , Osificación Heterotópica/etiología , Traumatismos de los Nervios Periféricos/diagnóstico por imagen , Traumatismos de los Nervios Periféricos/epidemiología , Traumatismos de los Nervios Periféricos/etiología , Nervio Peroneo/diagnóstico por imagen , Nervio Peroneo/lesiones , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/epidemiología , Falla de Prótesis , Radiografía , Recuperación de la Función , Reoperación/instrumentación , Reoperación/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone.