Sport after total hip arthroplasty: undoubted progress but still some unknowns.

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges. Cite this article: Bone Joint J 2020;102-B(6):661-663.

Acetabular impaction grafting in total hip replacement.

BACKGROUND AND PURPOSE: Acetabular impaction grafting has been shown to be very effective, but concerns regarding its suitability for larger defects have been highlighted. We report the use of this technique in a large cohort of patients, and address possible limitations of the technique. METHODS: We investigated a consecutive group of 339 cases of impaction grafting of the cup with morcellised impacted allograft bone for survivorship and mechanisms for early failure. RESULTS: Kaplan Meier survival was 89.1% (95% CI 83.2 to 95.0%) at 5.8 years for revision for any reason, and 91.6% (95% CI 85.9 to 97.3%) for revision for aseptic loosening of the cup. Of the 15 cases revised for aseptic cup loosening, nine were large rim mesh reconstructions, two were fractured Kerboull-Postel plates, two were migrating cages, one was a medial wall mesh failure and one had been treated by impaction alone. INTERPRETATION: In our series, results were disappointing where a large rim mesh or significant reconstruction was required. In light of these results, our technique has changed in that we now use predominantly larger chips of purely cancellous bone, 8-10 mm3 in size, to fill the cavity and larger diameter cups to better fill the aperture of the reconstructed acetabulum. In addition we now make greater use of i) implants made of a highly porous in-growth surface to constrain allograft chips and ii) bulk allografts combined with cages and morcellised chips in cases with very large segmental and cavitary defects.

A review of 202 periprosthetic fractures--stem revision and allograft improves outcome for type B fractures.

We report a retrospective review of the outcome of treatment of 202 periprosthetic fractures around total hip arthroplasty (THA) from two specialised arthroplasty centres. Fractures were classified according to the Vancouver classification. The aim was to evaluate treatment methods with respect to stem revision and grafting. Transverse B1 fractures treated with stem revision compared to those treated with open reduction and internal fixation (ORIF) with a plate showed a trend towards improved overall union rate (OR=2, p=0.6, 95% CI:0.14-28.4) and shorter times to union (p=0.038, mean 12 months SD 6.573 for ORIF versus 4.48 months SD 0.757 for stem revision). B2 fractures undergoing stem revision and grafting were significantly more likely to unite compared to ORIF alone (OR=17.3, p=0.018 95%CI:1.63-184.4). B3 fractures presented with significant variation in fracture configuration and bone loss and therefore their treatment was individualised. When treated with stem revision and grafting healing was achieved in a mean time of 7 months (n=81). Periprosthetic fractures of the femur are highly complex and challenging. Stem revision for transverse B1 fractures is now considered as a viable treatment modality as this fracture configuration is difficult to control with single plating, and fixation with a long stem bypassing the distal fracture line is necessary to achieve axial stability and healing. Bone allografting, whether used as a cortical onlay or in morselised impacted form for B2 and B3 fractures enhances fracture healing.

Contemporary cementing technique and mortality during and after Exeter total hip arthroplasty.

The Exeter universal stem implanted with contemporary cementing technique has shown an excellent survivorship at 15 years. The technique used for implantation calls for prolonged pressurization preventing blood from the femur exiting into the femoral canal, but this technique is not accepted widely as some surgeons believe it is associated with significant morbidity. This concern prompted this review. From 1988 to 2005, 9082 primary total hip arthroplasty (THA) were implanted. We identified all patients who died within 30 days from surgery. When available, the postmortem results were reviewed. Twenty-one patients died within 30 days from their primary THA (prevalence, 0.23%). There was one intraoperative death (prevalence, 0.01%). The postmortem report was consistent with fat embolism. Two additional patients died the same day of surgery from cardiac processes. No other deaths could be linked to cement. Sudden death during cemented THA with a current contemporary cementing technique and a specialized anesthetic protocol is nearly zero.

The use of long cemented stems for femoral impaction grafting in revision total hip arthroplasty.

BACKGROUND: Following revision total hip arthroplasty involving femoral impaction grafting, fractures usually have occurred distal to a standard-length stem in an area of weakened bone that was left inadequately supported. The purpose of the present study was to determine whether the use of a long stem decreases the rate of femoral fracture after revision hip surgery. We hypothesized that the use of a long-stem femoral component would decrease the risk of these fractures. METHODS: From 1991 to 2000, 567 revision total hip arthroplasties were performed with use of femoral impaction grafting. Of these, forty-two procedures in forty patients (average age, 73.8 years) were performed with use of a stem that was > or = 220 mm in length. The average number of previous revisions was 1.85. Thirty-four of the forty hips with preoperative radiographs had preoperative bone loss that was classified as grade III or IV according to the Endo-Klinik system. Major complications were recorded, and survival analysis was performed. RESULTS: No patient was lost to follow-up. Sixteen patients (sixteen hips) died at an average of fifty-two months postoperatively. The average duration of clinical follow-up for the hips in which the implant survived for more than forty-eight months was 7.5 years. The rate of major postoperative complications was 29%. Two postoperative femoral fractures occurred. Six patients (six hips) required a femoral reoperation. The survival rate with revision hip surgery as the end point was 90% at both five and ten years. The rate of survival with any failure as the end point was 82% at five years and 64% at ten years. CONCLUSIONS: The use of a long stem for femoral impaction grafting did not completely resolve the problem of postoperative fractures in these patients with substantial loss of bone stock undergoing revision hip surgery. Poor bone stock, technical errors, and other patient-related factors continue to account for the high postoperative fracture rate.

Intramedullary strut substitution and impaction allografting cemented revision for the treatment of a periprosthetic fracture in a severely compromised femur.

Revision for the treatment of a B3 periprosthetic femoral fracture often requires proximal femoral allograft arthroplasty in physiologically young or tumor prostheses in elderly patients. Extramedullary strut allograft augmentation can only be used when the host femur is structurally adequate for the insertion of the revision stem (periprosthetic femoral fractures type B2) and appears to be an attractive biological concept as early incorporation to the host bone results in a sound biomechanical construct. We report here the simultaneous use of whole femur intramedullary strut substitution along with an extramedullary strut graft placement, with impaction allografting revision to a long cemented femoral prosthesis, to augment the deficient metadiaphyseal bone stock (Paprosky type IV) for the treatment of a complex type B3 periprosthetic femoral fracture.

Dynamic compression plates for Vancouver type B periprosthetic femoral fractures: a 3-year follow-up of 18 cases.

BACKGROUND: There is no consensus on the best surgical treatment of periprosthetic femoral fractures. We report our experience with a dynamic compression plate. PATIENTS AND METHODS: We reviewed the results of 18 periprosthetic femoral fractures treated with open reduction and internal fixation using the dynamic compression plate (DCP). There were 7 Vancouver type B1, 2 type B2 and 9 type B3 fractures. 16 cases had previously undergone at least one revision procedure. In addition to a DCP plate, all B2 and B3 fractures were revised to cemented prostheses, and all B3 fractures were revised with impaction grafting. Mean follow-up was 39 months. RESULTS: The mean healing time for those 11 cases that united was 13 months. One B1-type and one B3-type fracture with plate fracture within 8 months of surgery failed to heal. Furthermore, one B1-type fracture and one B2-type fracture failed and developed nonunion. 3 patients died, from causes not related to surgery, within 8 months after surgery without signs of healing. INTERPRETATION: Open reduction and internal fixation using DCPs seems to be a valid method for the treatment of postoperative periprosthetic femoral fractures with stable stem in place. If the stem is unstable, we suggest that DCPs may be used in association with femoral revision using a long stem. In cases with stable stem (B1), we are inclined to agree with other authors that additional fixation using an extramedullary cortical strut graft may be necessary to improve stability and promote final healing.