Staged Revision Hip Arthroplasty With Femoral Impaction Bone Grafting for Prosthetic Joint Infections: Radiostereometric Analyses and Clinical Outcomes at Minimum 5-Year Follow-Up.

BACKGROUND: There are ongoing concerns regarding the use of bone graft following prosthetic joint infection and subsequent implant subsidence. The aim of this study was to determine whether the use of a cemented stem combined with femoral impaction bone grafting (FIBG) at second stage revision for infection results in stable femoral stem fixation, determined by accurate methods, and good clinical results. METHODS: A prospective cohort of 29 patients underwent staged revision total hip arthroplasty for infection using an interval prosthesis followed by FIBG at the final reconstruction. The mean follow-up was 89 months (range, 8 to 167 months). Femoral implant subsidence was measured with radiostereometric analysis. Clinical outcomes included the Harris Hip Score, Harris Pain score and Société Internationale de Chirurgie Orthopédique et de Traumatologie activity scores. RESULTS: At 2-years follow-up the median stem subsidence relative to femur was -1.36 mm (range, -0.31 to -4.98), while the cement subsidence relative to femur was -0.05 mm (range, 0.36 to -0.73). At 5-years follow-up, the median stem subsidence relative to femur was -1.89 mm (range, -0.27 to -6.35), while the cement subsidence relative to femur was -0.06 mm (range, 0.44 to -0.55). There were 25 patients who were confirmed infection-free after the second stage revision with FIBG. The median Harris Hip Score improved from 51 pre-operatively to 79 at 5 years (P = .0130), and Harris Pain score from 20 to 40 (P = .0038). CONCLUSIONS: Stable femoral component fixation can be achieved with FIBG when reconstructing the femur after revision for infection without compromising infection cure rates and patient-reported outcomes.

Long-Term Outcomes of Staged Revision Surgery for Chronic Periprosthetic Joint Infection of Total Hip Arthroplasty.

Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty. Staged revision surgery is considered effective in eradicating PJI. We aimed to determine the rate of infection resolution after each stage of staged revision surgery (first stage, repeat first stage, second stage, excision arthroplasty, and reimplantation) and to assess functional outcomes and the mortality rate at ten years in a consecutive series of 30 chronic PJI of total hip arthroplasties. Infection resolution was defined as no clinical nor laboratory evidence of infection at 24 months after the last surgery and after a minimum of 12 months following cessation of antimicrobial treatment. Four patients died within 24 months of their final surgery. Nineteen patients, 73% (worst-case analysis (wca) 63%), were infection free after 1 surgery; 22 patients, 85% (wca 73%), were infection free after 2 surgeries; and 26 patients, 100% (wca 87%), were infection free after three and four surgeries. The median Harris Hip Score was 41 prior to first revision surgery and improved to 74 at twelve months and 76 at ten years after the final surgery. Thirteen patients died at a mean of 64 months from first revision, giving a mortality rate of 43% at ten years, which is approximately 25% higher than that of an age-matched general population. The results show that with repeated aggressive surgical treatment, most PJIs of the hip are curable. Ten years after successful treatment of PJI, functional outcomes and pain are improved and maintained compared to before initial surgery, but this must be balanced against the high 10-year mortality. Level of evidence: cohort studies.

Structured-mentorship Program for Periacetabular Osteotomy Resulted in Few Complications for a Low-volume Pelvic Surgeon.

BACKGROUND: The Bernese periacetabular osteotomy (PAO) is a complex surgical procedure with a substantial learning curve. Although larger hospital and surgeon procedure volumes have recently been associated with a lower risk of complications, in geographically isolated regions, some complex operations such as PAO will inevitably be performed in low volume. A continuous structured program of distant mentoring may offer benefits when low numbers of PAOs are undertaken, but this has not been tested. We sought to examine a structured, distant-mentorship program of a low-volume surgeon in a geographically remote setting. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify the clinical results of PAO performed in a remote-mentorship program, as determined by patient-reported outcome measures and complications of the surgery; (2) to determine radiographic results, specifically postoperative angular corrections, hip congruity, and progression of osteoarthritis; and (3) to determine worst-case analysis of PAO survivorship, defined as nonconversion to THA, in a regionally isolated cohort of patients with a high rate of followup. METHODS: Between August 1992 and August 2016, 85 PAOs were undertaken in 72 patients under a structured, distant-mentorship program. The patients were followed for a median of 5 years (range, 2-25 years). There were 18 males (21 hips) and 54 females (64 hips). The median age of the patients at the time of surgery was 26 years (range, 14-45 years). One patient was lost to followup (two PAOs) and one patient died as a result of an unrelated event. Patient-reported outcome measures and complications were collected through completion of patient and doctor questionnaires and clinical examination. Radiographic assessment of angular correction, joint congruity, and osteoarthritis was undertaken using standard radiology software. PAO survivorship was defined as nonconversion to THA and is presented using worst-case analysis. The loss-to-followup quotient-number of patients lost to followup divided by the number of a patients converted to THA-was calculated to determine quality of followup and reliability of survivorship data. RESULTS: The median preoperative Harris hip scores of 58 (range, 20-96) improved postoperatively to 78 (range, 33-100), 86 (range, 44-100), 87 (range, 55-97), and 80 (range, 41-97) at 1, 5, 10, and 14 years, respectively. Sink Grade III complications at 12 months included four relating to the PAO and one relating to the concomitant femoral procedure. The median lateral center-edge angle correction achieved was 22° (range, 3°-50°) and the median correction of acetabular index was 19° (range, 3°-37°). Osteoarthritis progressed from a preoperative mean Tönnis grade of 0.6 (median, 1; range, 0-2) to a postoperative mean of 0.9 (median, 1; range, 0-3). Six hips underwent conversion to THA: five for progression of osteoarthritis and one for impingement. At 12-year followup, survivorship of PAO was 94% (95% confidence interval [CI], 85%-98%) and survivorship with worst-case analysis was 90% (95% CI, 79%-96%). The loss-to-followup quotient for this study was low, calculated to be 0.3. CONCLUSIONS: When PAO is performed using a structured process of mentoring under the guidance of an expert, one low-volume surgeon in a geographically isolated region achieved good patient-reported outcomes, a low incidence of complications at 12 months, satisfactory radiographic outcomes, and high survivorship. A structured distant-mentorship program may be a suitable method for initially learning and continuing to perform low-volume complex surgery in a geographically isolated region. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Mentoring in complex surgery: minimising the learning curve complications from peri-acetabular osteotomy.

PURPOSE: The aim of this study was to determine whether a complex surgical procedure such as peri-acetabular osteotomy could be safely learnt by using a programme involving mentoring by a distant expert. To determine this, we examined the incidence of intra-operative complications, the acetabulum correction achieved, the late incidence of re-operation and progressive degenerative arthritis. METHODS: Between 1992 and 2004, peri-acetabular osteotomy was performed in 26 hips in 23 patients. The median follow-up was ten (5-17) years. The median age of the patients at operation was 28 (14-41) years. Clinical outcomes were reported and radiographic results were determined by an independent expert. RESULTS: There were no intra-articular osteotomies, sciatic nerve injuries, hingeing deformities or vascular injuries. There was one ischial nonunion. The lateral centre-edge angle improved from a median 4° pre-operatively to 25°. One revision osteotomy, one osteectomy and three total hip replacements were required, two for progression of osteoarthritis. CONCLUSIONS: The programme of mentoring was successful in that there was a low incidence of the major intra-operative complications that are often reported during the learning curve period and the acetabular corrections achieved were similar to the originators.

Circulating RANKL is inversely related to RANKL mRNA levels in bone in osteoarthritic males.

INTRODUCTION: The relationship of circulating levels of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) with the expression of these molecules in bone has not been established. The objective of this study was to measure, in humans, the serum levels of RANKL and OPG, and the corresponding levels in bone of mRNA encoding these proteins. METHODS: Fasting blood samples were obtained on the day of surgery from patients presenting for hip replacement surgery for primary osteoarthritis (OA). Intraoperatively, samples of intertrochanteric trabecular bone were collected for analysis of OPG and RANKL mRNA, using real time RT-PCR. Samples were obtained from 40 patients (15 men with age range 50 to 79 years, and 25 women with age range 47 to 87 years). Serum total RANKL and free OPG levels were measured using ELISA. RESULTS: Serum OPG levels increased over the age range of this cohort. In the men RANKL mRNA levels were positively related to age, whereas serum RANKL levels were negatively related to age. Again, in the men serum RANKL levels were inversely related (r = -0.70, P = 0.007) to RANKL mRNA levels. Also in the male group, RANKL mRNA levels were associated with a number of indices of bone structure (bone volume fraction relative to bone tissue volume, specific surface of bone relative to bone tissue volume, and trabecular thickness), bone remodelling (eroded surface and osteoid surface), and biochemical markers of bone turnover (serum alkaline phosphatase and osteocalcin, and urinary deoxypyridinoline). CONCLUSION: This is the first report to show a relationship between serum RANKL and the expression of RANKL mRNA in bone.