Femoral impaction allografting for significant bone loss in revision hip arthroplasty.

INTRODUCTION: Femoral impaction bone allografting in revision hip arthroplasty facilitates physiological reconstruction with restoration of bone stock, allowing implantation of a standard cemented femoral component. The purpose of this study was to report our experience in femoral component revision arthroplasty with impaction morsellised cancellous bone allograft using custom impactors and a cemented triple-taper polished stem. METHODS: Retrospective analysis of all cases of femoral component revision hip arthroplasty with impaction bone grafting undertaken by a single surgeon from 2005 to 2011. Outcome measures included radiographic analysis of stem subsidence over time, graft remodelling and incorporation, and clinical progress. RESULTS: We reviewed 47 consecutive hips in 44 patients, mean age 62 years (37-88). Femoral impaction with allograft was performed as either single stage (41 cases) or 2-stage (6 cases) procedures. All patients received a cemented C-stem prosthesis. The mean follow-up period was 5.1 (1.3-9.4) years. The median preoperative bone defect score was 3 (interquartile range [IQR] 2-3) using the Endo-Klinik classification. Radiological evidence of graft incorporation was observed in 89% (281 of 315 zones) with additional remodelling observed in 33% (103 of 315 zones). The median stem subsidence at 1-year follow-up was 1.1 mm (standard deviation [SD] 1.24 mm, range 0-6 mm). The median Oxford Hip Score at the most recent follow-up was 36.5. To date no femoral component has undergone further revision. CONCLUSIONS: Encouraging results have been obtained with this technique for the treatment of significant bone loss in revision hip arthroplasty, allowing implantation of a standard prosthesis.

Total hip arthroplasty after acetabular fracture: incidence of complications, reoperation rates and functional outcomes: evidence today.

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan-Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P=0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P=0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.

Impaction bone grafting and cemented stem revision in periprosthetic hip fractures: a novel surgical technique.

With an ageing population, and increasing longevity of hip arthroplasty prostheses, the incidence of periprosthetic femoral fractures is rising. We present a simple and easily reproducible technique for reduction of any periprosthetic fracture that requires bone graft augmentation. This method facilitates impaction bone grafting to reconstitute lost bone stock and revision using a cemented implant.

The role of the transverse acetabular ligament in total hip arthroplasty.

We performed a systematic literature review to evaluate the role of the transverse acetabular ligament as a reference aid when determining acetabular component anteversion in total hip arthroplasty. We conducted a literature search in the MEDLINE, EMBASE and Pubmed databases using the key words 'transverse acetabular ligament' and 'arthroplasty'. Four studies published between 2006 and 2011, reporting on 1,217 procedures met our inclusion and exclusion criteria and were eligible for final evaluation. Outcome measures were the ability to identify the transverse acetabular ligament, anteversion of the acetabular component and dislocation rate. The methodological quality of the studies was variable and they were not homogenous enough for metaanalysis. We found that there was good evidence for the use of the transverse acetabular ligament in terms of accuracy of acetabular component anteversion. However, the ligament could not be routinely identified intra-operatively and other methods of determining the correct anteversion are recommended in this situation. The dislocation rate using this technique was low but it must be stressed that the cause of postoperative dislocation in total hip arthroplasty is multi-factorial and cannot solely be attributed to acetabular component orientation.

Implant longevity, complications and functional outcome following proximal femoral arthroplasty for musculoskeletal tumors: a systematic review.

A systematic review of the literature was undertaken to evaluate the outcomes and complications following proximal femoral arthroplasty for primary or metastatic tumors affecting the proximal femur. Six hundred sixty-eight patients were available for review. The length of resection ranged from 92 to 212 mm. Limb salvage rate reached over 90%. At 5 years the implant survival rate was 84% and at 10 years, it was 70%. The overall revision rate was 11.1%. Prevalence of venous thrombo-embolic (VTE) events was 8.5%, dislocation rate was 5.8%, infection was 5.2%, local tumor reoccurrence was 4.7%, perioperative mortality was 1.5%, and periprosthetic fracture was 0.6%. Where it was provided the Musculoskeletal Tumour Score was 70.8%. The implants tend to outlive patients with metastatic disease and high-grade localized disease, providing them with a relatively pain-free limb with good mobility and quality of life.

Impaction grafted bone chip size effect on initial stability in an acetabular model: Mechanical evaluation.

INTRODUCTION: Acetabular bone defect reconstruction is an increasing problem for surgeons with patients undergoing complex primary or revision total hip replacement surgery. Impaction bone grafting is one technique that has favourable long-term clinical outcome results for patients who undergo this reconstruction method for acetabular bone defects. Creating initial mechanical stability of the impaction bone graft in this technique is known to be the key factor in achieving a favourable implant survival rate. Different sizes of bone chips were used in this technique to investigate if the size of bone chips used affected initial mechanical stability of a reconstructed acetabulum. METHODOLOGY: Twenty acetabular models were created in total. Five control models were created with a cemented cup in a normal acetabulum. Then five models in three different groups of bone chip size were constructed. The three groups had an acetabular protrusion defect reconstructed using either; 2-4 mm(3), 10 mm(3) or 20 mm(3) bone chip size for impaction grafting reconstruction. The models underwent compression loading up to 9500 N and displacement within the acetabular model was measured indicating the initial mechanical stability. RESULTS: This study reveals that, although not statistically significant, the largest (20 mm(3)) bone chip size grafted models have an inferior maximum stiffness compared to the medium (10 mm(3)) bone chip size. INTERPRETATIONS: Our study suggests that 10 mm(3) size of bone chips provide better initial mechanical stability compared to smaller or larger bone chips. We dismissed the previously held opinion that the biggest practically possible graft is best for acetabular bone graft impaction.

Nailed cementoplasty: a salvage technique for rorabeck type II periprosthetic fractures in octogenarians.

Periprosthetic femoral fractures around a total knee arthroplasty present a surgical challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate cement in 5 patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and simulates a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their preinjury functional status within 4 months. This procedure does not disrupt the soft tissue envelope around the fracture site, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction, nailed cementoplasty is proposed as a salvage procedure in octogenarians unfit for lengthy interventions.

Periprosthetic femoral fractures around hip arthroplasty: current concepts in their management.

Peri-prosthetic fractures (PFF) are complex management problems in orthopaedic surgery. Their treatment has evolved with advances in principles of internal fixation and revision hip surgery. Current classification systems look at anatomical location, prosthesis stability and bone quality. Recent evidence highlights the importance of fracture stability in treatment planning, the weaknesses of single plating, the increasing role of long stem revision and also the importance of bone allografts. We present the principles of management of both intra and post-operative PFFs, including surgical techniques and published outcomes.

Methicillin resistant Staphylococcus aureus versus methicillin sensitive Staphylococcus aureus adult haematogenous septic arthritis.

INTRODUCTION: Septic arthritis is an orthopaedic emergency and Staphylococcus aureus (SA) is the number one cause. Methicillin resistant Staphylococcus aureus (MRSA) is increasing in incidence but how it differs from methicillin sensitive Staphylococcus aureus (MSSA) septic arthritis is unclear. Our aim was to delineate the differences in clinical features and outcomes between patients with MRSA and MSSA septic arthritis. MATERIALS AND METHODS: We performed a retrospective review of all adult patients presenting to our institute over a 5 year period from June 2000 to June 2005 with haematogenous septic arthritis. We identified 15 cases of MRSA and 43 cases of MSSA septic arthritis. Fisher's exact test and the Student's t-test were used in analysis. RESULTS: MRSA and MSSA predominantly affected males 60 versus 79%. MRSA cases were older with a mean age of 76 versus 44 years (P < 0.05), and had more comorbidities with a mean of 2.7 versus 1.35 (P < 0.05). In MRSA and MSSA cases the main sources of sepsis were unknown (20 vs. 47%), intravenous lines (47 vs. 2%), soft tissue infection (13 vs. 2%) and intravenous drug use (7 vs. 49%). MRSA was significantly more associated with intravenous line sepsis (P < 0.05), soft tissue infection (P = 0.05) and to be nosocomial (P < 0.05). MSSA was significantly more associated with IVDU (P < 0.05). Presentation was similar in both groups although MRSA patients were significantly more likely to be pyrexial (80 vs. 40%, P < 0.05) and to have glenohumeral involvement (P < 0.05) while MSSA was significantly more likely to affect the knee (P < 0.05). There were no significant differences between the total length of antimicrobial therapy in MRSA and MSSA patients (43 vs. 38 days, P > 0.2), or the number of surgical interventions required (1.8 vs. 1.6, P > 0.2). However MRSA patients were significantly more likely to be placed on inappropriate empirical antimicrobials pending sensitivities (93 vs. 0%, P < 0.05). Outcomes were similar in MRSA and MSSA patients with no significant differences in recurrences (0 vs. 10%, P > 0.2) or sepsis related mortality (13.3 vs. 6.9%, P > 0.2). MRSA, however, did show a strong towards a higher all cause 6 month mortality (26 vs. 7%, P = 0.07). CONCLUSION: MRSA septic arthritis tends to affect older patients with multiple comorbidities and has a tropism for the glenohumeral joint while MSSA has a tropism for the knee. We did not find a significant difference in required length of antimicrobials, number or requirement of operative interventions or outcomes in terms of number of recurrences or sepsis related mortality. However MRSA septic arthritis patients were found to have a strong trend towards an increased all cause 6 month mortality and were significantly more likely to receive inappropriate empirical antimicrobials.