Is single-anaesthetic bilateral total hip replacement using cemented stems safe and appropriate? A review of four decades of practice.

BACKGROUND: Symptomatic bilateral hip osteoarthritis can be treated surgically with either staged or single-anaesthetic bilateral total hip replacement (BTHR). Today the typical candidate for BTHR is more likely to receive cementless implants. We present the experience of BTHR at our institution using cemented stems combined with cemented and uncemented sockets and, to our knowledge, the largest prospective single-centre series. PATIENTS AND METHODS: This cohort study reviews all patients (319 patients: 638 hips) having BTHR at our institution between December 1977 and December 2015. No case was lost to follow-up. Data were collected prospectively but reviewed retrospectively. Length of stay and complication rates were included, and data were compared with Hospital Episode Statistics figures for operations carried out between March 2005 and June 2014 to confirm local database validity. Patient experience and Oxford Hip Scores were obtained for a subgroup of this cohort, comparing them with patients who underwent bilateral staged operations performed within 1 year. RESULTS: The rates for mortality, deep vein thrombosis, non-fatal myocardial infarction within 6 months were each 0.3% (1 episode) and non-fatal pulmonary embolism 0.6% (2 episodes). There were no intraoperative periprosthetic fractures or readmissions within 30 days. CONCLUSIONS: Our study shows a low risk of complications when using cemented and hybrid BTHRs for selected patients and the risk of complications compares favourably with published results. Available functional scores compared favourably to a comparison group of patients undergoing bilateral staged procedures, and a positive impression on treatment experience from a subgroup of interviewed BTHR patients was noticeable.

An Analysis of Reported Cases of Fracture of the Universal Exeter Femoral Stem Prosthesis.

BACKGROUND: Between 1991 and 2008, approximately 80 cases of fracture (neck or stem) have been reported. This study aimed at determining factors predisposing to implant fracture. METHODS: Clinical, surgical, radiological, and retrieval data were collated. Risk factors associated with fracture were categorized to patient related (weight and activity levels), surgical related (poor medial support, component size, and placement), and anatomic/implant related (head size/offset). RESULTS: Data was available on 60 patients (32 stem and 28 neck fractures). Mean patient age at fracture was similar for both neck and stem fractures (69 years, 67 years, respectively). Also, 77% neck and 52% stem fractures occurred in men. Mean weight was 107 kg in neck and 96.5 kg in stem fractures with 68% neck and 38% stem fractures either obese or morbidly obese. Mean time to fracture was 78 months (range, 36-144 months) for neck and 76 months (range, 2-155 months) for stem fractures. 44#2 and 44#3 were the most common sizes associated with neck fractures. Stem fractures occurred more commonly (84%) in the smaller sizes (35.5 to 44#1). Elongated femoral heads were used in 69% neck and 14% stem fractures. CONCLUSION: Neck fractures were most commonly associated with patient-related (increased weight and activity) and implant-related (use of an elongated femoral head) factors. Stem fractures were most commonly associated with correctable surgical-related causes, predominantly secondary to stem undersizing or inadequate medial support (84%).

The results of acetabular impaction grafting in 129 primary cemented total hip arthroplasties.

Between 1995 and 2003, 129 cemented primary THAs were performed using full acetabular impaction grafting to reconstruct acetabular deficiencies. These were classified as cavitary in 74 and segmental in 55 hips. Eighty-one patients were reviewed at mean 9.1 (6.2-14.3) years post-operatively. There were seven acetabular component revisions due to aseptic loosening, and a further 11 cases that had migrated >5mm or tilted >5° on radiological review - ten of which reported no symptoms. Kaplan-Meier analysis of revisions for aseptic loosening demonstrates 100% survival at nine years for cavitary defects compared to 82.6% for segmental defects. Our results suggest that the medium-term survival of this technique is excellent when used for purely cavitary defects but less predictable when used with large rim meshes in segmental defects.

Extended trochanteric osteotomy followed by cemented impaction allografting in revision hip arthroplasty.

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.

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.

Femoral impaction grafting in revision total hip arthroplasty: a follow-up of 540 hips.

Between 1987 and 1999, 540 revision total hip arthroplasties in 487 patients were performed at our institution using the femoral impaction grafting technique with a cemented femoral stem. All patients were prospectively followed up for 2 to 15 years postoperatively with no loss to follow-up. A total of 494 hips remained successfully in situ at an average of 6.7 years. The 10-year survival rate was 98.0% (95% confidence interval, 96.2-99.8) with aseptic loosening as the end point and 84.2% (95% confidence interval, 78.5-89.9) for reoperation for any reason. Indication for surgery and the use of any kind of reinforcement significantly influenced outcome (P < .001). This is the largest known series of revision THA with femoral impaction grafting, and the results support continued use of this technique.

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.

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.

The long-term results of the original Exeter polished cemented femoral component: a follow-up report.

We present a long-term follow-up report of the results of the original Exeter polished cemented stems inserted between November 1970 and the end of 1975 at our institution by surgeons of widely differing experience using crude cementing techniques. The results of this series were reported in 1988 (Fowler et al. Orthopaedic Clinics of North America. 1988;19:477) and again in 1993 (Timperley et al. Journal of Bone and Joint Surgery. 1993;75-B:33). There have been no failures from aseptic femoral component loosening since the 1993 report. From the original series of 433 hips, there were, at the end of 2003, 26 living patients with 33 hips. Of the latter, there were 25 hips in 20 patients with their original femoral components still in situ. Twenty-eight (6.46%) hips from the original series have been lost to follow-up, although none since 1992. With the end point reoperation for aseptic stem loosening, the survivorship is 93.5% (95% confidence interval, 90.0%-97.0%). The reoperation rate for aseptic femoral component loosening is 3.23% into the 33rd year of follow-up.

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.

Posterior longitudinal split osteotomy for femoral component extraction in revision total hip arthroplasty.

We present a technique of single posterior longitudinal split osteotomy. This technique allows the expansion of the proximal femur and easier extraction of uncemented femoral components. Since 1998 we have performed this osteotomy in 12 revision total hip arthroplasties in 11 patients who had either stable fibrous ingrowth or a small amount of bony ingrowth. All were revised to a cemented Exeter stem (Stryker Benoist Gerard, Caen, France). No patient required conversion from a longitudinal split to an extended trochanteric osteotomy. At mean follow-up of 48 months, there were significant improvements in both pain and function. There were no complications due to this technique. Mean in-cement taper engagement (subsidence) was 1.1 mm (range, 0-2 mm). Femoral impaction grafting did not adversely affect the cement mantle or increase in-cement taper engagement. With appropriate patient selection, this is a simple, reliable, and extensile technique to assist in the extraction of uncemented ongrowth femoral components whether hydroxyapatite-coated or not.

The Exeter Universal hip in patients 50 years or younger at 10-17 years' followup.

UNLABELLED: The Exeter Universal hip (Stryker Inc., Newbury, UK) has reported survival rates of 91.74% at 12 years in all patients with reoperation as an endpoint. However, its performance in younger patients has not been fully established. We reviewed survivorship and the clinical and radiographic outcomes of this hip system implanted in 107 patients (130 hips) 50 years old or younger at the time of surgery. The mean age at surgery was 42 years. The minimum followup was 10 years (mean, 12.5 years; range, 10-17 years) with no patients lost to followup. Twelve hips had been revised. Of these, nine had aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation and one joint underwent revision for infection. Radiographs demonstrated 14 (12.8%) of the remaining acetabular prostheses were loose but no femoral components were loose. Survivorship of both stem and cup from all causes was 92.6% at an average of 12.5 years. Survivorship of the stem from all causes was 99% and no stem was revised for aseptic loosening. The Exeter Universal stem performed well, even in the young, high-demand patient. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Impaction allografting revision for B3 periprosthetic femoral fractures using a Mennen plate to contain the graft: a technical report.

We prospectively evaluated the long-term results of a technique using the Mennen plate to contain impacted allograft and support cemented Exeter stem revision fixation for the treatment of three B3 periprosthetic femoral fractures (PFFs). Three patients with a median age of 77 years were followed-up for a median of 84 months. In all cases the stem bypassed the distal fracture line by a median length of 85 mm (median ratio over femoral diameter = 2.13). The median postoperative Charnley-Merle d'Aubigné-Postel score for pain, function and range of movement was 5, 3 and 6 respectively. Impaction allografting revision could be used for B3 PFFs when the stem bypasses the most distal fracture line by at least two ipsilateral femoral diameters. The Mennen plate can aid to contain the impacted allograft and to maintain fracture reduction and short term stability thereafter, but the long stem is necessary for long-term stability and healing.

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.

Large pelvic giant cell tumor: a case report and a review of current treatment modalities.

Giant cell tumors (GCTs) of bone typically present in adults between the ages of 20 and 50 with the symptoms of progressive pain and local swelling. Females are slightly more often affected than males. GCTs tend to arise in epiphyses of long tubular bones. The typical radiographic appearances are of geographical radiolucency and cortical thinning, without internal mineralization. GCTs represent 5% of all primary bone tumours. Although benign, GCTs are locally aggressive entities producing expansive and lytic lesions. We present the case of a young man with a GCT of his pelvis who could not be treated by previously described methods because of the size of the lesion, its location, and the effects it had on surrounding bony structures.

The management of periprosthetic femoral fractures around hip replacements.

Periprosthetic femoral fractures are increasing in frequency and in complexity. They occur intra-operatively, or post-operatively, when they are frequently associated with loosening, with or without osteolysis. Periprosthetic femoral fractures usually occur at low energy levels, either after falls or spontaneously during activities of daily living. At present, the Vancouver classification system probably comes closest to the ideal, as it considers the fracture configuration, the stability of the implant and the quality of the bone stock. When the stem is stable, open reduction and internal fixation is suggested. Several authors have used strut grafts for the treatment of periprosthetic femoral fractures, with good results. If the stem is loose, or revision is indicated for other reasons, it is generally advisable to by-pass the most distal fracture line with a longer stem prosthesis by at least two femoral diameters. Augmentation of this intra-medullary fixation with an external cortical strut to improve rotational stability and/or internally with impaction allografting to compensate for bone defects is also advisable. Vigilant post-operative clinical and radiological assessment following total hip replacement should identify those with recurrent dislocation, loosening, subsidence and osteolysis. These patients are at greatest risk of developing femoral periprosthetic fractures.

Dall-Miles plates for periprosthetic femoral fractures. A critical review of 16 cases.

Fourteen patients with 16 periprosthetic femoral fractures around hip replacement were treated with Dall-Miles plates between June 1996 and February 2000. There were 10 Vancouver B3, three B1 and three type C fractures. In addition to a Dall-Miles plate, two of the fractures (one B3 and one C type) were also stabilised with one strut graft and nine B3 fractures were revised with impaction grafting. Of the three B1 fractures treated with plates, two failed through fracture of the plate. A further two patients with B3 fractures treated with plates also failed with fracture of the plate. Failure of these plates occurred within 6 months of surgery. All non-unions and fixation failures in this series were in cases where the femoral component did not bypass the most distal fracture line by at least two cortical diameters. The Dall-Miles plates and cable system alone is insufficient for the treatment for periprosthetic femoral fractures. It must be supplemented with additional intramedullary or extramedullary fixation.