Outcome of revision hip arthroplasty.

Background. Clinical material collected from 1989 to 1999 from three orthopedic centers is discussed: the Orthopedic Clinic at the Center for Postgraduate Medical Education in Otwock, the Orthopedic Clinic at the Lublin Academy of Medicine, and the Orthopedic Clinic at the Warsaw Academy of Medicine.
Material and methods. During this period 511 patients with an average age of 66 were treated. The authors explain the reasons for aseptic loosening of hip prostheses, the types of implants replaced, and the methods of surgical treatment.
Analysis of results. The importance of correct surgical technique and modern cementing methods during primary arthroplasty for the duration of good prosthesis functioning is discussed. A good outcome from revision arthroplasty can be expected only when the decision to treat is made early. The authors confirm the usability of impacted camcellous allografts for revision hip arthroplasty. Complications during and after surgery are also discussed. Difficulties in the clinical and radiological evaluation of treatment outcomes caused by differing criteria used in each orthopedic treatment are also discussed in this article.
Conclusions. In the conclusion the authors propose rules for surgical treatment to reduce the number of revision procedures.

Problems, progress, and late outcome from the treatment of septic loosening of hip arthroplasty.

Background. The goal of this research was to evaluate problems and progress in the treatment of septic loosening of total hip replacements. These complications are typically the result of unfamiliarity with the risk factors, technical errors during surgery, improper management by physicians, or other factors, sometimes difficult to ascertain. The bacteria which cause injections are identified, and the methods used to control and manage infections are described.
Material. The authors studied complicating infections in hip prostheses in 129 patients. This clinical material was divided into two groups: 31 patients with early infections and no indications of prosthesis loosening were assigned to Group I, while Group II included 98 patients with symptoms of late infection and signs of endoprosthesis loosening. Surgical treatment of early infection involved thorough debridement of the focus and many weeks of antibiotic therapy, both local and systemic.
Results. In 21 cases complete healing was obtained. Due to recurrence of the infection, removal of the endoprosthesis was necessary in 10 cases. For the 98 patients with late infection, healing of the infection was noted in75 joints (76%) following removal of the focus of injection along with the endoprosthesis and cement. Poor outcome as measured by pain and persistent fistulae, was obtained in 11 joints (11,5%). Only in 12 patients (12,5%) was the endoprosthesis implanted without recurrence of the infection, obtaining, a good treatment outcome.
Conclusions. The basic factors reducing the risk of causing septic loosening of the endoprosthesis are familiarity with the risk factors, the proper antibiotic prevention, the command of the requiste surgical skill and a high level of asepsis in the operating theater. The most commonly observed final outcome of treatment of the sequelae of septic loosening of the prosthesis is unstable pendent hip. Repeat implantation of an endoprosthesis can be considered in younger patient when healing of the infection has been confirmed clinically and biochemically.

[Osteosynthesis of infected and impaired growth of the femur with vascularized fibular graft]. / Osteosynteza w leczeniu septycznych powiklan zrostu kosci udowej unaczynionym przeszczepem strzalki.

The authors present the causes of difficulties arising during treatment of infected non-unions. Much attention was paid to the unique character of the infection in the thigh and the technical problems related to it. The role of vascularized bone grafts was emphasised. Different possibilities of surgical treatment of bone loss in different localisations were presented basing on clinical material of 7 patients. The authors used various osteosynthesis techniques, most frequently external fixators. Graft healing anf remodelling with different kind of fixators is discussed. The frequency of graft fractures was stressed. The differences in the healing of graft fractures and normal fractures was discussed. The need of suitable elasticity of the external fixator for the correct healing of the transplant and its remodelling was emphasised.

[Results of treating septic non-unions of the tibia with vascularized bone grafts and the Zespol stabilizer]. / Wyniki leczenia septycznych powiklan zrostu goleni unaczynionym przeszczepem kosci i stabilizatorem Zespol.

The authors present their experiences with various applications of the Zespol stabilizer and different kinds of vascularized bone transfers used in the treatment of septic non-unions of the tibia. The clinical material consisted of 24 patients with infections of the lower extremities treated with different vascularized bone transplants. The Zespol method was used in 23 cases. Compression osteosynthesis was applied every time with the stabilizer placed over the skin. The necessity of mounting the stabilizer far from the bone did not influence the stability of the osteosynthesis. Depending on the length of the transplant single or multiple plare supports were used. Additional plaster cast was applied only during wound healing. No loosening of the stabilizer was observed. The importance of early weight bearing in order to achieve bone union and remodelling of the bone graft is strongly emphasized by the authors. The described treatment allows bone union within 8 months on average. The advantages of the Zespol stabilizer in treatment of complicated disturbances of bone union are presented.

[Stress fracture of free vascularized bone grafts]. / Zlamania zmeczeniowe wolnych unaczynionych przeszczepów kosci.

Three cases of stress fracture within free vascularized bone graft were found among 35 patients with completed treatment. In 32 years old male stress fracture of free vascularized fibular graft used for tibial reconstruction occurred after a dozen of one (operated) leg hops. In 29 years old female operated due to tibial pseudoarthrosis with free vascularized iliac wing graft the fracture appeared after couple of days of intense walking. In both cases fracture occurred after incorporation of the graft, several months after removal of the external fixator. Pain and swelling of the limb increased over couple of days. In the last case of 25 years old male vascularized fibula transferred to the femur fractured in the presence of external fixator one year after surgery in the course of remodeling of the graft. In all cases X-ray revealed transverse fracture line in the middle of the graft. Plaster cast immobilization has been used in one case only. Graft remodeling with marked hypertrophy was found 4 month later.

The application of allogenic bone grafts for replantation of a hip prosthesis; an attempt at radiological evaluation of graft rebuilding.

UNLABELLED: An attempt at radiological estimation of remodelling of allogenic bone grafts used in reconstruction of bone stock in revision of hip arthroplasty. THE METHOD: x-ray pictures of the treated hips were taken immediately and at 3, 6 and 12 months after surgery. Changes of bone structure around the prosthesis were estimated. THE RESULTS: symptoms of remodelling (presence of newly formed bone trabecules between host bone and the grafts and in the surrounding area) were encountered at 3 to 6 months after reconstruction surgery. CONCLUSIONS: radiological estimation of bone remodelling remains subjective. Nevertheless it can help to determine bone graft rebuilding in revision surgery of the hip.

External fixation in treatment of false joints and bone losses using vascularized grafts.

Different kind of external fixator osteosynthesis in the treatment of pseudoarthroses and bone defects with vascularized bone grafts are presented. Construction features of different external fixators are discussed based on clinical material of 48 patients, who have had different vascularized bone graft surgery. For tibia treatment mainly external plate ixator "Zespol" was used. Its advantages such as simplicity of construction, small size and weight and easy application are presented. The possibility of joining the external plates allowes using this method in the treatment of bone defects of arbitrary length. Some restrictions of this method are also pointed out. Fixators of larger size were used for treatment of femoral pseudoarthroses and bone defects. Emphasis was put on advantages and disadvantages of multiplane static fixators and unilateral fixators. The importance of weight bearing and dynamization for bone healing process were discussed. It seems that external fixator whose construction allows to adjust the dynamization level at various stages of the healing process is the best method of treatment of complications of bone union.

[Distal femur reconstruction with vascularized fibular graft: indications and surgical technique]. / Rekonstrukcja dalszego odcinka kosci udowej uszypulowana strzalka--wskazania i technika operacyjna.

Indications and surgical technique of distal femur reconstruction with vascularized fibular graft and fibular vessels pedicle are presented. The method is used in femoral metaphyseal defects combined with knee stiffness as safer procedure than free vascularized fibular graft. A case of 23 years old male with vast defect of distal femur after fracture complicated with osteomyelitis is presented. Good result of treatment has been achieved 18 months after surgery despite fracture of previously incorporated fibular graft.

[Radial bone reconstruction with free vascularized fibular osteocutaneous graft: a case report]. / Rekonstrukcja kosci promieniowej wolnym unaczynionym przeszczepem strzalki z wyspa skórna--opis przypadku.

Radial shaft has been reconstructed in 14 years old boy with free vascularized graft. Fifteen by four cm skin island has been harvested along with the fibula and served to fill the defect within the forearm. Proximal end of radial artery has been microsurgically anastomosed to peroneal artery of the flap and peroneal vein branch with basilic vein. The bone healed after 3 months, remodeling took 5 months and overgrowth 8 months. The role of microsurgery in treatment for this type of injury has been emphasized.

[Complex tissue reconstruction of the arm with free vascularized fibular graft with skin island]. / Zlozone rekonstrukcje wielotkankowe ramienia z zastosowaniem wolnego unaczynionego przeszczepu strzalki z wyspa skórna.

Results of treatment for postraumatic bone and soft tissue defects within the arm in 3 patients (1 female, 2 males aged 20-30 years (mean 25 years), are presented. In both male patients osteomyelitis and irreversible radial nerve lesion was present. Stage 1 included radical excision of inflamed tissues. When the inflammation ceased reconstructive treatment has been initiated. Tendon transposition has been performed to restore writ and fingers extension. After several months free vascularized fibular graft (11-17 cm in length) was used to reconstruct bone and soft tissues of the arm. Zespol fixator has been used in two cases. Marginal skin island necrosis has been noted twice. Screw tract infection or lack of bony union in proximal end of the graft required re-operation. Bony union has been observed already in the 3rd month postoperatively but final incorporation and hypertrophy of the graft occurred after 6-26 months, (mean 14 months). In all cases final results were rated as excellent.

[Free vascularized double barrel fibular graft for reconstruction of femoral deficit--case report and surgical techniques]. / Wolny unaczyniony przeszczep podwójnie zlozonej strzalki w rekonstrkcji ubytku kosci udowej--opis przypadku i techniki operacyjnej.

A case of 18 years old female treated for 11 cm femoral deficit due to comminuted fracture and secondary osteomyelitis is described. Free vascularized double barrel fibular graft has been used. The detailed delineation of surgical technique is given. Ten months after surgery complete healing and incorporation of the graft was found; the external fixation was removed. Excellent functional result has been achieved.

[Reconstruction of the femur with free vascularized bone graft]. / Rekonstrukcja kosci udowej wolnym unaczynionym przeszczepem strzalki-opis przypadku.

A case of post-infection femoral bone loss treated with free vascularized fibular graft is presented. The healing process is discussed; an attention is directed towards thickening of the graft along with progressive weight bearing. The usefulness of Zespol fixation in those cases, allowing for early rehabilitation is underlined.

[Vascularized bone graft treatment for pseudoarthrosis of the leg]. / Leczenie stawów rzekomych goleni unaczynionym przeszczepem kosci.

The use of pedicular and free vascularized grafts in treatment for pseudoarthrosis of the leg is discussed in this paper. These grafts are greatly useful in treatment of avascular pseudoarthrosis where severe vascular impairment is present. The transplantation of viable, vascularized bone graft to the site of pseudoarthrosis creates ultimate environment for bony union. A concomitant soft tissue transfer (muscles and skin) may compensate for potential skin defect at the recipient site. According to the authors the above discussed method deserves broader application in the treatment of pseudoarthroses, especially avascular ones.