Clinical outcome and survival rate of the Herbert ulnar head prosthesis for reconstruction of the distal radioulnar joint depending on co-morbidity and different indications.

INTRODUCTION: Ulnar head prostheses have been developed to restore the integrity of the DRUJ and relieve pain. This study aims to evaluate the long-term outcome of the clinical and radiographic results as well as the survival rate of the Herbert ulnar head prosthesis (UHP) depending on co-morbidity and different indications. MATERIALS AND METHODS: The Herbert ulnar head prosthesis was implanted in 62 patients. In the majority of the patients, the indication was given due to pain during forearm rotation. This was on account of painful instability of the distal ulna following Bowers (59.7%) or Kapandji procedure (16.1%), Darrach procedure (8.1%) or painful post-traumatic (12.9%) or primary osteoarthritis (3.2%). Of the 62 patients, 34 were men and 28 women. The mean age at the time of operation was 49 years (range 18-84 years). A clinical and radiographic evaluation was performed including pain scale, range of motion, grip strength and the DASH and modified Mayo wrist scores. RESULTS: The average follow-up was 84.5 months (range 8-206 months), and statistically significant reduction of pain was observed (p < 0.05). The range of motion of pro- and supination improved slightly, but not significantly, whereas the DASH score improved significantly from 56 to 43 (p < 0.05). Patients without an arthrodesis achieved better results in the DASH and in the modified Mayo wrist score. In 39 cases, a small amount of bone resorption was seen at the collar of the prosthesis in the follow-up radiographs. A revision surgery was necessary in 14 patients. The Kaplan-Meier survival rate after 15 years was 90.3%. CONCLUSION: The long-term results of the UHP are encouraging regardless of different indications with a survival rate of more than 90% 7 years following surgery, high patient satisfaction and good clinical and radiographic results. LEVEL OF EVIDENCE: IV.

Custom-made wrist prothesis (UNI-2™) in a patient with giant cell tumor of the distal radius: 10-year follow-up.

Wrist endoprosthesis is still an exceptional indication compared to the prosthesis of large joints, especially when a rescue surgery procedure of the wrist is no longer possible and the complete wrist arthrodesis is to be considered the ultima ratio. However, a suspended function in the wrist is accompanied by a significant restriction in the patient`s daily life. Using the fourth-generation endoprosthesis, the situation regarding long-term results for the hand has already improved. This means that a durability of more than 6 years is no longer a rarity. Defect situations in joints, in particular those which occur after tumor, still pose a greater challenge. If autologous reconstructions cannot be performed, custom-made prostheses can be considered as very rare indications for joint reconstruction. While these have been used for years on large joints such as shoulder, elbow, knee and hip, they have only been described on the hand in particular cases. We report the 10-year follow-up of implantation of a custom-made wrist prothesis (UNI-2™, KMI, Germany) in a 36-year-old patient with tumorous destruction of the distal radius by a giant cell tumor.

[Revision surgery after total wrist arthroplasty]. / Revisionen nach Implantation von Totalendoprothesen am Handgelenk.

BACKGROUND: Wrist arthroplasty is still an exceptional indication in the field of hand surgery. In recent years, it has become increasingly accepted as an alternative to wrist arthrodesis as the ultima ratio for panarthrosis or similar destruction of the wrist. In particular, the patient's desire for functional integrity also plays an important role. COMPLICATIONS: While there were often complications with earlier prosthesis designs of the older generations and only a short survival rate could be achieved, this has improved, if the indication of the so-called fourth generation prostheses is done properly. Survival rates of over 10 years are no longer uncommon, even without revision operations. Currently, the indication for hemiarthroplasty has been increasing, particularly in the case of post-traumatic destruction. Those who are seriously interested in endoprosthesis should also be able to treat the associated complications. The present article is intended to provide an overview of common or potential complications in the context of wrist arthroplasty and to demonstrate possible solutions by presenting case studies. The basics of primary implantation are, therefore, not discussed. Reference is made to further literature.

Progress of instability in fragility fractures of the pelvis: An observational study.

Fragility fractures of the pelvis (FFP) are an increasing entity among elderly persons. Characteristics are different from high-energy pelvic trauma. Little is known about the natural course of FFP in conservative and after operative treatment. MATERIALS AND METHODS: Medical charts and radiologic data of 148 patients with an FFP, who were admitted in a 3-year period, were analysed retrospectively. Incidence and characteristics of fracture progression (FP) were noted. RESULTS: Patients presenting early after a traumatic event had more often non-displaced fractures, fractures with lower FFP Type classification and were more frequently treated conservatively. FP was observed in 21 cases (14.2%), twenty times after conservative and once after operative treatment. FP under conservative treatment occurred in female patients only. Patients with FP were younger than patients without. FP occurred in all fracture types, most frequently in FFP Type I. A second CT scan was positive for FP in 39.2% of patients with prolonged pain or restricted mobility. CONCLUSION: FP is a real phenomenon, occurring in a minority of FFP patients. Female patients are at highest risk. Repeated CT scan is positive in nearly 40% of patients with continuing pain or restricted mobility. Operative treatment is a good preventive measure of FP as FP does only exceptionally occur after operative fixation of FFP.

Results after arthroscopic treatment of central traumatic lesions of the triangular fibrocartilage complex.

INTRODUCTION: Injuries of the triangular fibrocartilage complex (TFCC) are of high clinical relevance; however, the clinical evidence for treatment is poor and long-term results are rarely published. The purpose of this study was to evaluate the clinical outcome of symptomatic central traumatic lesions of the TFCC (Palmer 1A) following arthroscopic debridement. MATERIALS AND METHODS: Between 2007 and 2013, 87 patients were arthroscopically diagnosed with Palmer 1A lesion and accordingly treated with debridement. Follow-up was available for 43 patients. Activities of daily living (ADLs) were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Pain perception was evaluated with visual analogue scale (VAS 0-10). Grip strength and wrist motion were assessed with conventional techniques using a Jamar dynamometer and a goniometer. Patient satisfaction was assessed using a questionnaire at follow-up. RESULTS: Mean follow-up was 42.5 months (range 5-70). The mean age of the patients (22 male and 21 female) at time of surgery was 41 ± 15.9 years. No major complication occurred during surgery and follow-up. The DASH score (preoperatively 49.8 ± 19.3 vs. postoperatively 14.1 ± 17.9, p < 0.05) and pain perception (VAS: preoperatively 7.2 ± 2.0 vs. postoperatively 1.4 ± 1.6, p < 0.05) improved significantly. Grip strength was satisfactory after surgery (19.6 ± 13.1). Ulnar deviation improved significantly from 29.3 ± 10.4° to 35.6 ± 8.3° (p < 0.05) and wrist flexion improved from 53.8 ± 18.9° to 67.4 ± 12.9° (p < 0.05). Wrist extension, radial deviation, pronation and supination did not change significantly after surgery. Improved symptoms were reported by 41/43 (95.3%) patients and 40/43 (93%) patients would have had the same procedure again knowing the final outcome. Six of 43 patients (15%) had an ulnar plus variance. None of these needed ulnar shortening. CONCLUSIONS: Central traumatic TFCC lesions can safely be treated by arthroscopic debridement. We showed a sustained pain relief with significantly improved quality of life (DASH score) and wrist motion at follow-up. This resulted in a high patient satisfaction and acceptance of the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, level IV.

[Wrist arthrodesis with a fixed-angle, "low-profile" fusion plate without carpometacarpal joint fixation]. / Handgelenkarthrodese mit winkelstabiler "Low-profile"-Platte ohne karpometakarpale Fusion.

OBJECTIVE: Total wrist arthrodesis to improve functional use of the hand by reducing pain and increasing grip strength. INDICATIONS: Painful destruction of the radio- and midcarpal joints. CONTRAINDICATIONS: Analgesia and satisfactory hand function after motion-preserving surgical or conservative treatment. Chronic joint infection. SURGICAL TECHNIQUE: Posterior approach to the wrist. Removal of articular surfaces destroyed all the way down to cancellous bone. Filling of defects with cancellous bone graft taken from distal radius or iliac crest. Osteosynthesis with fixed-angle wrist fusion plate without carpometacarpal (CMC) III joint fixation. POSTOPERATIVE MANAGEMENT: Below-elbow cast for 2 weeks. Immediate active motion fingers exercises. X­ray control 6 weeks postoperatively. Gradual increase of normal hand use in daily life after bony consolidation. RESULTS: Total wrist arthrodesis was performed using a fixed-angle fusion plate without CMC III joint fixation in 28 patients (21 men, 7 women). A follow-up of 14/28 patients was performed at a mean of 21 (3-39) months postoperatively. Grip strength improved from 14 (0-38) kg preoperatively to 22 (12-40) kg postoperatively. The average postoperative DASH score was 40 (6-72) points. Pain measured with the VAS scale (0-10) improved from an average of 7 (3-10) points preoperatively to 2 (0-6) points postoperatively. Overall, 13/14 patients were satisfied with the treatment; 26/28 patients achieved primary bony consolidation. Postoperative complications found in 9 of 28 patients: 2 nonunion, pain in the CMC II (n = 3) or III (n = 1) joints, 2 screw breakage, 1 postoperative bleeding and 1 infection. Both cases of nonunion healed after plate removal, re-osteosynthesis with a straight wrist arthrodesis plate, bridging the CMC III joint, and a bone graft from the iliac crest. All patients with CMC II joint pain were pain-free after removal of the protruding screw. One patient had chronic pain in the CMC III joint despite plate removal. In the 2 cases with screw breakage, no issues caused. In one patient, after primary bony consolidation, removal of the plate was performed for extensor tenolysis and not as a result of the broken screw. In the second patient, removal of the plate after primary bony consolidation was unnecessary as the patient was pain-free in the area of the broken screw, yet a protruding screw in the CMC II joint cavity was removed.

[Primary intervention in Dupuytren's disease]. / Primäreingriff beim Morbus Dupuytren.

Partial aponeurectomy as the state-of-the-art treatment in Dupuytren's disease is indicated when minimally invasive forms of treatment, such as needle aponeurotomy or percutaneous collagenase injection, are not possible due to the advanced stage of the disease or the morphology of the contracture. Even in earlier stages of Dupuytren disease partial aponeurectomy has advantages in comparison to minimally invasive forms of treatment. These advantages are lower recurrence rates as well as less persistent residual contractures, especially in the proximal interphalangeal joint.

[Fractures of the thumb ray]. / Frakturen des Daumenstrahls.

Fractures of the first thumb ray are common and need accurate differential treatment to restore gripping hand functions. Displaced fractures of the distal and proximal phalanx of the thumb are often treated with screws or Kirschner wires. Stable fractures can also be treated non-operatively. Fractures of the base of the first metacarpal should be differentiated into extra-articular Winterstein fractures and intra-articular Bennett or Rolando fractures. Traction forces by the abductor pollicis longus tendon regularly lead to displacement of the shaft of the first metacarpal; therefore, these fractures usually require reduction and fixation. Good functional results can be achieved by operative treatment. Fractures of the trapezium are rare. If they are displaced, operative treatment is recommended to prevent osteoarthritis of the first carpometacarpal joint.

Current concepts for the treatment of acute scaphoid fractures.

Fractures of the scaphoid are common injuries, accounting for approximately 80 % of carpal fractures. Differentiation between stable and unstable fractures (Herbert classification) cannot be made with conventional X-rays, so evaluation by computed tomography should additionally be performed. Under most circumstances, minimally invasive surgery with cannulated screws is the treatment of choice. A longer cast immobilization after minimal-invasive surgery is not necessary. Conservative treatment still has a place if the fracture is not dislocated nor unstable, but operative treatment can be offered to reduce the period of cast immobilization. Displaced fractures have a greater risk for nonunion and therefore should be treated operatively. Proximal pole fractures are definitely unstable, requiring treatment with screw fixation. The surgical approach depends on the location of the fracture and the preference of the surgeon.

[Bone Necrosis of the Hand]. / Knochennekrosen der Hand.

The bone necrosis of the hand is a common disease of the bone-cartilage complex. In principle, every bone of the hand can be affected. Compared to other osteonecroses of the hand the necrosis of the lunate occurs most frequently. Other diseases such as osteonecrosis of the Os scaphoideums (Morbus Preiser) are much rarer. Unfrequent diseases such as osteonecrosis of the metacarpal heads or all carpal bones are restricted to case descriptions. The lunate osteonecrosis leads to osteoarthritis of the wrist if untreated. A detailed clinical examination and adequate radiological diagnosis are essential. The lunate osteonecrosis is classified according to Lichtman and Ross based on radiographs. The treatment is being executed either conservatively or surgically, depending on the stage. In surgical treatment pressure relieving and revascularization procedures and rescue operations have been established. For all other osteonecroses of the hand no standardized therapy can be assigned because sufficient data are not available. Generally, the treatment for bone necroses of the hand should be found for each patient individually.

[Plastic surgical management in lower extremity sarcoma reconstruction]. / Plastisch-chirurgisches Management bei Weichgewebesarkomen an der unteren Extremität.

Tumors in the lower extremity with a critical size of over 5 cm diameter should principally be tested for being malignant soft-tissue sarcomas. If a soft-tissue sarcoma is present, radical oncological resection with sufficiently wide surgical margins is the most important cornerstone of curative therapy. No neoadjuvant or adjuvant treatment (radiotherapy or chemotherapy) can replace this treatment approach. Modern techniques of tumor resection as well as plastic-reconstructive surgery permit one to perform radical tumor excision in more than 95% of cases and to close large defects and to largely preserve function of the extremity by transplantation of muscles, tendons and bones as well as transplantations of nerves and blood vessels. The plastic reconstructions after radical tumor resection are often demanding and complex and require intensive interdisciplinary cooperation. This consists of the full spectrum of plastic surgical options, which should be performed in specialized centers and be specifically adapted to the patient and case profile. In this review different options for functional reconstruction after radical oncological removal of soft-tissue sarcomas are presented.

[Treatment of phalangeal fractures using the mini-hook plate. An alternative for surgical fixation of small phalangeal bone fragments?]. / Versorgung von Fingerfrakturen mit der Minihakenplatte. Alternative in der operativen Versorgung von knöchernen Ausrissen an den Phalangen?

BACKGROUND: Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate. PATIENTS AND METHODS: Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire. RESULTS: A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3 ° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed. CONCLUSION: Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.

[Scaphoid fractures and pseudarthrosis of the scaphoid]. / Skaphoidfrakturen und Skaphoidpseudarthrosen.

Scaphoid fractures are by 80 % the most common fractures of the carpal bones. Detection and treatment can be delayed due to only slight clinical symptoms, which are often shown by acute injuries of the scaphoid. Pseudarthrosis of the scaphoid developing arthrosis of the wrist or even a carpal collapse can be the consequence. An in-depth clinical examination and adequate radiological diagnostics are essential for the detection and the treatment of scaphoid fractures. A primary examination by CT scan is obligatory. The classification of Krimmer/Herbert in the CT is used to subdivide the scaphoid fractures. Depending on the appearance of the fracture a conservative or surgical approach is indicated. All stable fractures of the scaphoid can be treated conservatively. In all forms of unstable scaphoid fractures surgery is recommended. Different ways of surgical approaches and osteosyntheses are described. Pseudarthrosis of the scaphoid should be surgically reconstructed with osteosynthesis in combination with bone graft to prevent a carpal collapse.

Intraoperative C-arm CT imaging in angular stable plate osteosynthesis of distal radius fractures.

The purpose of this study was to analyze the practicability and benefit of intraoperative C-arm computed tomography (CT) imaging in volar plate osteosynthesis of unstable distal radius fractures. During a 1 year period, intraoperative three dimensional (3D) imaging with the ARCADIS Orbic 3D was performed in addition to standard fluoroscopy in 51 cases. The volar angular stable plate oesteosyntheses were analyzed intraoperatively and, if necessary, improved immediately. The duration of the scan and radiation exposure dose were measured. On average, performance of the scan and analysis of the CT dataset took 6.7 minutes. In 31.3% of the surgeries a misplacement of screws was detected and correction was done immediately. C-arm CT imaging can easily be integrated in the normal course of surgery. As a complement to the standard 2D-fluoroscopy, the C-arm CT is a useful tool to evaluate the quality of osteosynthesis.

Nailing versus plating for comminuted fractures of the distal femur: a comparative biomechanical in vitro study of three implants.

PURPOSE: The purpose of our study was to determine the biomechanical properties of three different implants utilized for internal fixation of a supracondylar femur fracture. The retrograde supracondylar nail (SCN), the less invasive stabilization system plate (LISS) and the distal femoral nail (DFN) were tested and their biomechanical properties compared. METHODS: Twenty pairs of fresh-frozen human femura were used. Each femur was osteotomised to simulate a comminuted supracondylar fracture (AO/OTA 33.A3) and then randomized to fracture fixation with either SCN (n=9) or LISS (n=9). Each contralateral femur was stabilized with DFN as a control (n=18). Two femur pairs were spent on pretesting. All femura were subjected to axial (10-500 N) and torsional (0.1-14 Nm) loading. RESULTS: Eighteen matched femur pairs were analyzed. The post-loading median residual values were 49.78, 41.25 and 33.51% of the axial stiffness of the intact femur and 59.04, 62.37 and 46.72% of the torsional stiffness of the intact femur in the SCN, LISS and DFN groups. There were no significant differences between the three implants concerning axial and torsional stiffness. CONCLUSIONS: All implants had sufficient biomechanical stability under physiological torsional and axial loading. All three implants have different mechanisms for distal locking. The SCN nail with the four-screw distal interlocking had the best combined axial and torsional stiffness whereas the LISS plate had the highest torsional stiffness.

[Comparative biomechanical studies on implant systems for the treatment of distal radius fractures: what are the conclusions for clinical practice?]. / Biomechanische Vergleichsstudien von Implantatsystemen zur Versorgung distaler Radiusfrakturen: Welche Schlussfolgerungen ergeben sich für die klinische Praxis?

AIM: This review evaluates which conclusions can be drawn for the clinical daily routine in operative treatment of distal radius fractures, regarding the published biomechanical studies concerning implant systems within the last 10 years. METHOD: After identification of 21 articles about biomechanical studies of implant systems for the treatment of distal radius fractures from a literature search, these articles were analysed concerning the specimens, the fracture model as well as the implants used. The quintessence was reviewed with regard to their clinical relevance. RESULTS: All tested palmar angular stable plate systems showed sufficient stiffness for holding the load transmission from the hand to the forearm also within active fist closure. There was no advantage of palmar angular stable plates concerning stiffness compared to dorsal angular stable plates. Angular stable plates are superior over non-angular stable plates in treatment of distal radius extension fractures. Locking screws should be preferred over locking pegs. Subchondrally placed screws have a higher stability than more proximal localised screws. When palmar plates with 2 rows of distal screw holes are used, the highest stability can be achieved by filling all screw holes. However using 2 screws in each row is sufficient. CONCLUSION: There were clinically relevant implications from the published biomechanical studies concerning implant systems for treatment of distal radius fractures in the last 10 years and their considerations provide a safer therapy of distal radius fractures. These are to be respected accordingly.

[Transfer of the posterior tibialis tendon to restore an active dorsiflexion of the foot]. / Die Tibialis posterior-Transposition zur Wiederherstellung einer aktiven Fußhebung.

After lesions of the peroneal nerve or damage of the tibialis anterior muscle a lack of active dorsiflexion leads to a drop foot deformity. Ober (1933) described a transfer of the posterior tibialis tendon to the dorsum of the foot to restore active extension of the foot. The aim of this retrospective study was to evaluate the results of this method and to compare our results with those in the literature.Between 1992 and 2004 we performed a posterior tibialis tendon transfer in 16 patients with an average age of 40 years. 10 patients suffered from complete peroneal nerve palsy, which was due to a traumatic lesion (n=8) or iatrogenic damage (n=2). 3 patients had an incomplete peroneal nerve palsy caused by iatrogenic lesion (n=2) and lumbar disc herniation (n=1). 3 patients demonstrated a malfunction of the anterior tibial muscle following a compartment syndrome. 14 patients were available for a clinical follow-up after an average of 64 months. Clinical assessment included the hindfoot, muscular strength, pain, limitation of function and subjective satisfaction. The clinical result was evaluated using the Stanmore score (0-100).8 patients were very satisfied and 2 were satisfied with their results, 4 patients were not satisfied. 11 patients had no pain. The active dorsal ankle extension averaged - 5.7° (10 to - 30°). The Stanmore score revealed an average of 62 points with an excellent result in 2, a good result in 5, a fair result in 2 and a poor result in 5 patients.Transfer of the posterior tibial muscle to restore active dorsiflexion of the foot is a therapeutic option. As it is known from the literature objective results were mostly fair, but there was a high degree of satisfaction among the patients.

[Osteoblasts : cellular and molecular regulatory mechanisms in fracture healing]. / Osteoblasten : Zelluläre und molekulare Regulationsmechanismen in der Frakturheilung.

Bone tissue possesses a unique regeneration ability, translating mechanical and metabolic stimuli into a biological response. The perpetual regeneration processes allow continuous self-renewal and adaptation to prevailing mechanical forces. The complex regulation of osteoblastic differentiation during fracture repair has not been completely defined. Two different transcription factors - RUNX2 and SP7 - are considered to be master genes of osteoblastic differentiation. Furthermore, the canonical WNT pathway plays an essential role in the activation of osteoblastic differentiation during both bone growth and fracture healing. Studies of fracture healing have revealed that downregulation of the WNT pathway causes a significant reduction in new bone formation. Moreover, correct WNT signalling is also required for BMP2-induced bone formation. There is increasing evidence that patients who develop recalcitrant fracture nonunions exhibit not only reduced numbers and differentiation capacity of osteogenic progenitors but also a significant downregulation of numerous factors in the WNT pathway. Therefore, better understanding of the WNT regulatory mechanisms could reveal new strategies for the treatment of delayed fracture healing and for the tissue engineering of bone.

[Multidirectional palmar fixed-angle plate fixation for unstable distal radius fracture]. / Multidirektionale winkelstabile Versorgung der instabilen distalen Radiusfraktur.

PURPOSE/BACKGROUND: Open reduction and internal fixation with plates is a valid treatment of displaced extra- and intra-articular distal radius fractures. This report presents our experience treating unstable distal radius fractures by using a multidirectional palmar fixed-angle plate system (Aptus(R) Radius 2.5 by Medartis). The subchondral support of the articular surface by fixed angle screws prevents secondary dislocation allowing early mobilisation. PATIENTS AND METHOD: 61 patients with distal radius fractures were treated during 6/2003 and 10/2004 using this palmar fixed-angle plate fixation without bonegraft. Postoperative X-rays showed anatomical reduction in all cases. 55 patients could be evaluated postoperatively. The follow-up examination included the patient's history, physical and radiographic examination as well as the DASH questionnaire and the Krimmer's modified Cooney wrist score. RESULTS: The average follow-up time was 9.6 +/- 5.2 months. The mean age of the examined patients was 53.9 +/- 17.8 years. The fractures were classified according to AO. There were eleven A3, four B2 and five B3 fractures, ten C1, 16 C2 and nine C3 fractures. All fractures united without complications. Just two cases showed a loss of length. At follow-up the average palmar angulation was 8 degrees , ulnar inclination 21 degrees and ulnar variance + 0.2 mm. Wrist motion averaged a decrease for extension and flexion of 12 %, for ulnar and radial deviation of 9 % and for pronation and supination only of 2 % in comparison to the uninjured side. Grip strength reached an average of 85 % of the contralateral side. Patients regained good function as represented in a mean DASH score of 14 points and a Krimmer score of 82 points. CONCLUSIONS: The treatment of unstable distal radius fractures with this plate fixation provided stable internal fixation and allowed early function. Due to multidirectional angle fixation and two lines of cortical screws it is possible to achieve an optimal restoration. The fixation of the central articular surface is guaranteed by the distal line, the dorsal subchondral support by the proximal line.

Cementless acetabular reconstruction and structural bone-grafting in dysplastic hips. Surgical technique.

BACKGROUND: Studies of acetabular reconstruction with use of cement and bulk bone graft have demonstrated increasing rates of cup failure in patients with dysplastic hips seven years after total hip arthroplasty. Comparable data on the long-term results of bulk bone-grafting done in conjunction with cementless implants are limited. The aim of this study was to review the clinical and radiographic results of autologous bulk bone-grafting in conjunction with a cementless cup. METHODS: From 1987 to 1992, forty-seven patients (forty women and seven men, with an average age of 50.4 years) who had developmental dysplasia of the hip underwent fifty-six total hip arthroplasties and received a structural graft in combination with a cementless Harris-Galante type-I cup. All patients were followed prospectively. In fifty-five hips, implant migration was measured with single-image radiographic analysis. RESULTS: After an average duration (and standard deviation) of 10.2 +/- 2.9 years, three patients (four hips) had died. In the surviving patients, four implants had been revised and two had radiographic evidence of loosening. With use of revision and loosening as end points, the eleven-year survival rates were 91.6% and 88.9%, respectively. Of the fifty implants that had no loosening, fourteen had measurable cup migration, thirty-five had no migration, and one implant could not be measured. All migrations but one were progressive. With loosening used as the end point, the survival rate at eleven years was 100% for the implants with no migration; however, the survival rate for the cups that had migrated was 69.3% (p = 0.0012). CONCLUSIONS: The eleven-year survival rate for the spherical press-fit cups in combination with bulk bone-grafting is satisfactory, given the complexity of these reconstructions. However, the difference between the survival of the implants that had migrated and those that had not was significant. We expect that the thirteen implants with progressive acetabular migration at the time of the latest follow-up are at risk for loosening, which will increase the revision rate for this series in the coming years.