Satisfying Results of Primary Hip Arthroplasty in Patients With Hip Dysplasia at a Mean Followup of 20 Years.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common cause of secondary osteoarthritis (OA) in younger patients, and when end-stage OA develops, a THA can provide a solution. Different options have been developed to reconstruct these defects, one of which is impaction bone grafting combined with a cemented cup. To determine the true value of a specific technique, it is important to evaluate patients at a long-term followup. As there are no long-term studies, to our knowledge, on THA in patients with DDH using impaction bone grafting with a cemented cup, we present the results of this technique at a mean of 15 years in patients with previous DDH. QUESTIONS/PURPOSES: We wished to determine (1) the long-term probability of cup revision at a minimum followup of 15 years for cemented acetabular impaction bone grafting in patients with DDH; (2) the radiographic appearance of the bone graft and radiographic signs of implant loosening; and (3) the complications and pre- and postoperative Harris hip scores with cemented THA combined with impaction bone grafting in patients with previous DDH. METHODS: Between January 1984 and December 1995 we performed 28 acetabular impaction bone grafting procedures for secondary OA believed to be caused by DDH in 22 patients; four patients died before 15 years, leaving 24 hips in 18 patients for retrospective analysis at a minimum of 15 years (mean, 20 years; range, 16-29 years). The diagnosis of DDH was made according to preoperative radiographs and intraoperative findings. All grades of dysplasia were included; five patients had Crowe Group I, eight had Group II, nine had Group III, and two had Group IV DDH. No patients were lost to followup. In all cases the acetabular defects were combined cavitary and segmental. Owing to the high number of deaths, we performed a competing-risk analysis to determine the probability of cup revision surgery. RESULTS: The competing-risk analysis showed cumulative incidences at 15 and 20 years, with endpoint revision for any reason of 7% (95% CI, 0%-17%), whereas this was 4% (95% CI, 0%-11%) with endpoint revision of the cup for aseptic loosening. Three revision surgeries were performed. Two cup revisions were performed for aseptic loosening at 12 and 26 years. Another cup revision was performed owing to sciatic nerve problems at 2 years. A stable radiographic appearance of the graft was seen in 19 of the 25 unrevised hips. Four hips showed acetabular radiolucent lines and two showed acetabular osteolysis. None of the unrevised cups showed migration or radiographic failure. Postoperative complications included a pulmonary embolus and a superficial wound infection. The Harris hip score improved from 37 (range, 9-72) preoperatively to 83 (range, 42-99) at latest followup. CONCLUSIONS: Cemented primary THA with the use of impaction bone grafting shows satisfying long-term results in patients with previous DDH. For future research it is important to evaluate this technique in a larger cohort with a long-term followup. Other techniques also should be evaluated at long-term followup to be able to compare different techniques in this important and specific patient group. LEVEL OF EVIDENCE: Level IV, therapeutic study.

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.

Surgical technique: Results of stabilization of sternoclavicular joint luxations using a polydioxanone envelope plasty.

BACKGROUND: Surgical treatment options for sternoclavicular joint luxations described in the literature are numerous, although all have limitations. Therefore, there is no favorable surgical treatment for sternoclavicular luxations when nonoperative treatment has failed. DESCRIPTION OF TECHNIQUE: We developed the polydioxanone (PDS) envelope plasty, a modification of the figure-of-eight technique, using a PDS ligament. METHODS: We retrospectively reviewed 39 patients (40 joints), treated with a PDS envelope plasty for invalidating sternoclavicular luxations. The minimum followup was 10 months (average, 52 months; range, 10-171 months). The Simple Shoulder Test (SST), Constant-Murley shoulder score, and subjective categorical results were recorded preoperatively and postoperatively. RESULTS: In most patients, postoperative functional shoulder scores were excellent (mean Constant-Murley score, 90, range, 52-100; mean SST, 10; range, 2-12). Ninety percent of patients had an improvement of shoulder function at followup. Only minor complications occurred. Thirteen percent of patients had spontaneous postoperative subluxations. However, the postoperative shoulder function improved in all these patients. CONCLUSIONS: The PDS envelope plasty is a simple procedure, a modification of the best-reported technique. We have promising results with high shoulder scores. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Long-term results of cemented total hip arthroplasty in patients younger than 30 years and the outcome of subsequent revisions.

BACKGROUND: The number of total hip arthroplasties in patients under 30 years is increasing over the years. Almost all of them will face at least one or more future revisions in their life. Therefore, the implant used should have a high survival rate, and needs to be easily revisable resulting in a low re-revision rate. Several studies have evaluated the outcome of total hip arthroplasties in patients under 30 years. However, only a few reported on the follow-up outcome of 10 years or more. In addition, none of these reports published data of the subsequent revisions of these implants within their original report. METHODS: We studied historically prospective collected data of 48 consecutive patients (69 hips) younger than 30 years, treated with a cemented primary total hip prosthesis between 1988 and 2004. Since the last evaluation of this cohort, two patients were lost to follow-up. For all hip revisions in this cohort, again cemented implants were used, mostly in combination with bone impaction grafting. Kaplan-Meier survival curves at 10- and 15 years for the primary total hip arthroplasties and revisions were determined. RESULTS: The mean age at time of primary surgery was 25 years (range, 16 to 29 years). Mean follow-up of the primary hips was 11.5 years (range, 7 to 23 years). During follow-up 13 revisions were performed; in 3 cases a two-stage total revision was performed for septic loosening and 9 cups were revised for aseptic loosening. There were no aseptic stem revisions. The 10 and 15-year survival rates with endpoint revision for aseptic loosening of the primary total hip were 90% (95% CI: 79 to 96) and 82% (95% CI: 65 to 92) respectively. None of our 13 subsequent revisions needed a re-revision within 10 years after re-implantation. CONCLUSIONS: Cemented total hip implants in patients under 30 years have an encouraging outcome at 10 and 15 years after surgery in these young patients. The 13 revised hips, treated with bone grafting and the third generation cement technique, were performing well with no re-revisions within ten years after surgery.

Revisions of extensive acetabular defects with impaction grafting and a cement cup.

BACKGROUND: Loosening of acetabular components often leads to bony defects. Management of extensive acetabular bone loss in hip revision arthroplasty can be a tremendous challenge. QUESTIONS/PURPOSES: We asked whether a reconstruction with impacted bone grafts will provide a durable and pain-free function in extensive acetabular defects. We specifically determined the (1) survival rates with the end point of revision for any reason, aseptic revision, and radiographic loosening; (2) visual analog scale (VAS) pain score, Harris hip score (HHS), and the Oxford Hip Questionnaire score (OHQS); (3) number of repeat revisions; (4) complications; and (5) radiographic loosening, wear, and radiolucencies. PATIENTS AND METHODS: We retrospectively followed 25 patients (27 hips) with extensive acetabular defects. No patient was lost to followup. Two patients died during followup. Minimum followup was 3 years (mean, 8.8 years; range, 3-14.1 years). RESULTS: Three patients (three hips) underwent repeat revision surgery and another two patients (two hips) had radiographically loose hips. The 10-year survival rate was 88% (95% confidence interval, 74.2%-100%) with the end point acetabular revision for any reason and 95% (95% confidence interval, 86.0%-100%) with the end point acetabular revision for aseptic loosening. The mean HHSs were 55 points before surgery and 72 points postoperatively. CONCLUSIONS: Acetabular reconstruction with impaction bone grafting and a cemented cup is a reliable technique with a 10-year survival rate of 88% in patients with extensive acetabular deficiencies. LEVEL OF EVIDENCE: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Good results with cemented total hip arthroplasty in patients between 40 and 50 years of age.

BACKGROUND AND PURPOSE: Total hip arthroplasties in young patients have lower long-term survival rates than in older patients. We evaluated the use of a unique treatment protocol in patients aged between 40 and 50 years. In all cases we used a cemented THA, and for acetabular deficiencies we also used impacted bone grafts together with a cemented cup. METHODS: In 140 consecutive patients who were between 40 and 50 years of age at index surgery, 168 cemented total hip prostheses were evaluated after a mean follow-up time of 10 (2-19) years. Acetabular deficiencies were reconstructed with wire meshes and impacted bone grafts with a cemented cup (70 hips). During follow-up, 18 patients died (27 hips); in this group 3 hips (3 patients) had been revised. None of the patients were lost to follow-up. In all surviving patients, clinical assessment was performed with hip-score questions and all radiographs were evaluated. RESULTS: All clinical questionnaires showed an improved clinical hip score. 29 hips (17%) were revised after a mean of 8 (0.3-18) years. Kaplan-Meier survival analysis showed a survival of 88% (95% CI: 82-94) after 10 years with revision of either component for any reason. Survival with endpoint revision for aseptic loosening of either component was 94% (95% CI: 90-99) after 10 years. INTERPRETATION: Cemented implants in young patients have satisfying long-term results. Reconstruction of acetabular deficiencies with impacted bone grafts show promising results.

Cemented polyethylene cups in patients younger than 40 years.

UNLABELLED: Although uncemented cup implants frequently are used in young patients, we believe long-term survival rates of cups in these patients are somewhat disappointing, and therefore we have continued to use cemented cups in primary THA, even in young patients. However, in cases of acetabular bone stock defects, we also use bone impaction grafting. We prospectively followed 130 patients with 175 cemented cups; no patients were lost to followup. The mean age of the patients at surgery was 31 years (range, 16-39 years). An acetabular reconstruction with bone impaction grafting was performed in 84 hips (48%). The minimum followup was 2 years (average, 8.1 years; range, 2.0-18.5 years). Twenty-one of the 175 cups (12%) were revised at an average of 8.1 years (range, 2.0-18.5 years). Reasons for revision were infection (one early, seven late), recurrent dislocations (two), traumatic loosening (one), and aseptic loosening (10). The 10-year survival rate of all cemented cups with end point of revision for any cause was 85%. Survival with end point of aseptic loosening of all cups was 92%. Survival with end point of revision for aseptic loosening was 90% for the cups without impaction grafting and 95% for the cups with impaction grafting. We believe cemented acetabular cups in young patients have acceptable midterm survival; however, in the case of acetabular bone defects, we recommend reconstruction with impaction grafting. LEVEL OF EVIDENCE: Level III, therapeutic study.

No effect of bone morphogenetic protein-7 (OP-1) on the incorporation of impacted bone grafts in a realistic acetabular model.

Bone morphogenetic proteins (BMPs) accelerate bone repair in experimental and clinical conditions. Impacted Morsellized Cancellous Bone grafts (MCB) are successfully used to reconstruct bone defects after failed hip implants. The main question in this study was if BMP-7 (OP-1) mixed with MCB could accelerate the incorporation of MCB and prevents the formation of a soft tissue interface after remodeling of the MCB. A large loaded defect in the acetabulum of goats was reconstructed with a wire mesh and with MCB or MCB mixed with OP-1. After 6 weeks, no differences were found in the revascularization process, in the number of osteoclasts resorbing the MCB, and in the thickness and appearance of the fibrous interface between MCB with or without OP-1. After 6 weeks, enchondral bone had formed in the bone graft layer and on the periosteal anterior and superior rim in the OP-1 group only. More periosteal bone and more bone in the holes of the mesh had been formed in most OP-1 goats. Most MCB was replaced by new lamellar bone after 15 weeks in both groups. We speculate that during or directly after impaction most of the OP-1 is released from the carrier inducing an early effect outside the reconstructive layer at the periosteal side of the acetabulum. Probably most OP-1 has left the reconstruction by the time new vessels and progenitors reached the bone graft. These results do not support the use of OP-1 in impaction bone grafting in patients.

Acetabular Reconstructions with Impaction Bone-Grafting and a Cemented Cup in Patients Younger Than 50 Years of Age: A Concise Follow-up, at 27 to 35 Years, of a Previous Report.

We present an update of 19 acetabular reconstructions, performed with a cemented total hip arthroplasty and impaction bone-grafting, in situ at the time of our previous report. At a mean follow-up of 30 years (range, 27 to 35 years), no additional patients were lost to follow-up. Two patients (3 reconstructions) died for reasons unrelated to the hip surgery. Five reconstructions (5 patients) were revised, 4 for aseptic loosening and 1 for septic loosening, after a mean of 24 years (range, 22 to 27 years), leaving 11 surviving hips (11 patients) that were clinically and radiographically evaluated. Kaplan-Meier survival at 30 years was 0.40 (95% confidence interval [CI], 0.23 to 0.56) for revision for any reason, 0.56 (95% CI, 0.35 to 0.73) for aseptic loosening, and 0.53 (95% CI, 0.33 to 0.69) for radiographic loosening. Competing risk analysis showed that Kaplan-Meier analysis overestimates the revision risk by 18% for revision for any reason and 22% for aseptic loosening. Cemented impaction bone-grafting is a reasonable long-term solution for demanding primary and revision acetabular reconstructions in young patients with acetabular bone defects. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone impaction grafting for corticosteroid-associated osteonecrosis of the knee.

BACKGROUND: Osteonecrosis of the distal portion of the femur produces a segment of dead bone in the weight-bearing portion of the femoral condyle, frequently associated with subchondral fracture and collapse and eventually resulting in secondary osteoarthritis. Treatment of these late stages of osteonecrosis in the knee can be problematic. The purpose of the present study was to evaluate a new surgical technique in which the subchondral osteonecrotic lesion is removed. The bone defect is then reconstructed with impacted bone grafts to prevent collapse and/or to regain distal femoral sphericity. METHODS: In this prospective, one-surgeon study, nine consecutive knees in six patients were studied, all of which had extensive corticosteroid-associated osteonecrotic lesions of the femoral condyles. Six knees had collapsed lesions when they were initially treated. The mean age of the patients was thirty-one years. Both the clinical and radiographic outcomes were assessed at a minimal follow-up time of two years. RESULTS: At a mean follow-up time of fifty-one months, none of the reconstructed knees had been converted to a total knee prosthesis. The objective Knee Society score improved from a mean of 63 to 89 points. The functional Knee Society score improved from a mean of 19 to 81 points. During the follow-up period, there was no progression of collapse observed; however, three knees showed early signs of osteoarthritis. Clinical success was achieved in six of eight knees, and radiographic success was achieved in seven of nine knees. CONCLUSIONS: At the time of writing (at the time of midterm follow-up), this method appears attractive as a joint-preserving procedure. It is a relatively simple procedure that is not likely to interfere with future knee procedures. It appears that this technique can be effective in knees with collapse of the femoral condyle, and it may delay the need for a total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

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.

Femoral component revision with use of impaction bone-grafting and a cemented polished stem.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of revision of the femoral component of a hip arthroplasty with use of an impaction bone-grafting technique and a cemented polished stem. METHODS: Thirty-three consecutive femoral reconstructions that were performed between March 1991 and February 1996 with use of the X-change femoral revision system, fresh-frozen morselized allograft, and a cemented polished Exeter stem were followed prospectively. Femoral bone stock defects were classified according to the Endoklinik classification. The average age of the patients at the time of the femoral component revision was sixty-three years. No patient was lost to follow-up, which was performed at a minimum of eight years, but eight patients had died. None of the deaths was related to the surgery. RESULTS: No femoral reconstruction had been rerevised at a mean of 10.4 years postoperatively. There was one unrecognized intraoperative fracture, which healed following nonoperative treatment. There were three postoperative femoral fractures, all through cortical defects at the level of the tip of the prostheses. All fractures healed after plate fixation, and all femoral implants were left in situ. The average subsidence of the stem within the cement mantle was 3 mm; seven stems migrated > or =5 mm. The average Harris hip score improved from 49 points prior to surgery to 85 points (range, 68 to 100 points) at the time of this review. Subsidence did not affect the Harris hip score. Kaplan-Meier analysis, with an end point of femoral revision for any reason, showed a survival rate of 100% (one-sided 95% confidence interval, 100% to 91.3%). CONCLUSIONS: Femoral revision with use of an impaction bone-grafting technique and a cemented polished stem resulted in an excellent prosthetic survival rate at eight to thirteen years postoperatively. The major problem that occurred was a femoral fracture in four patients.

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.

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old.

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.

Prosthetic fitting in a patient with a transtibial amputation due to a congenital vascular malformation of the right leg.

BACKGROUND: The problems of prescribing a prosthesis for a young girl with severe congenital vascular malformation deformity leading to a transtibial amputation. CASE DESCRIPTION AND METHODS: Due to the high risk of recurrent bleeding and limitations regarding full weight bearing of the stump, a normal socket fitting process was not possible. Using a multidisciplinary approach, a prosthesis was designed to enable full weight bearing in a flexed knee position with ischial tuberosity support to prevent full weight bearing on the tibial part of the stump. FINDINGS AND OUTCOMES: After training and adjustments to the design, a definitive prosthesis with a free motion mechanical knee joint could be used. During the training with this prosthesis, no skin problems were observed, and at the end of the rehabilitation, the patient had a high level of activities of daily living and sports. CONCLUSION: The above prosthetic solution with an adjusted socket design proved to be successful in this case. Clinical relevance In a patient with severe congenital vascular malformation deformity leading to a transtibial amputation, fitting of a good prosthesis without full weight bearing of the stump proved to be successful.

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.

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old: a concise follow-up, at twenty to twenty-eight years, of a previous report.

In a previous report, we presented our results of forty-two acetabular reconstructions, performed with use of impaction bone-grafting and a cemented polyethylene cup, in thirty-seven patients who were younger than fifty years and had a minimum of fifteen years of follow-up. The present update study shows the results after twenty to twenty-eight years. Eight additional cups had to be revised--four because of aseptic loosening, three because of wear, and one during a revision of the stem. Three additional cups were considered loose on radiographs. Survivorship of the acetabular reconstructions, with an end point of revision for any reason, was 73% after twenty years and 52% after twenty-five years. With revision for aseptic loosening as the end point, survival was 85% after twenty years and 77% after twenty-five years; for signs of loosening on radiographs, survival was 71% at twenty years and 62% at twenty-five years. In conclusion, our previous results have declined but the technique of using impacted morselized bone graft and a cemented cup is useful for the purpose of restoring bone stock in young patients whose acetabular defects require primary or revision total hip arthroplasty.