Dual mobility cups associated with proximal femoral replacement in nontumoral indications: Results and complications.

INTRODUCTION: Reconstruction of extensive proximal femoral bone loss is a major challenge during total hip arthroplasty (THA). Proximal femoral replacement (PFR), initially used for bone tumors, is an alternative to allograft-prosthetic composite reconstruction. However, PFRs present a high complication rate, particularly related to dislocation. Moreover, dual mobility cups (DMCs) are effective in preventing dislocation, and no study has yet assessed their association with PFRs. Therefore, the aim of this study was to assess the dislocation and complication rates in THA using PFRs with DMCs. HYPOTHESIS: The use of a DMC decreases the dislocation rate associated with PFRs in nontumoral indications. METHODS: From 2008 to 2017, 66 PFRs associated with a DMC (40 women, mean age=71 years [26-94]) were included in our total joint registry and retrospectively reviewed. The main indications were complex periprosthetic and pertrochanteric fractures (26 THAs, 40%), aseptic loosening (22 THAs, 33%) and periprosthetic joint infections (18 THAs, 27%). A single design of PFR implant was used (Global Modular Replacement System (GMRS), Stryker, Mahwah, NJ, USA) with an uncemented stem in 54 THAs (82%). RESULTS: Eighteen complications (27%) were reported at a mean follow-up of 4.6 years [2-10]: 5 dislocations (7.5%), 9 periprosthetic joint infections (13.6%), 2 aseptic loosening (3%) and 2 femur fractures (3%). Overall survivorship at 5 years was 72% (95% CI: 58-82). Survivorship free from dislocation was 94% (95% CI: 85-98) at 1 year. The mean Harris Hip Score was 70±16.4 [26-100] at latest follow-up. CONCLUSION: The use of DMCs limits the risk of PFR dislocation, in comparison to other series in the literature that used large femoral heads, without compromising implant survivorship. In addition, DMCs make it possible to overcome the potential risks of mechanical failure associated with constrained acetabular components. LEVEL OF EVIDENCE: IV; retrospective cohort.

Reconstruction of proximal femoral bone loss using circumferential structural allograft during total hip arthroplasty in a young patient.

Management of proximal femoral bone loss during hip arthroplasty in young patients is a complex problem due to the need to provide a joint with an increased longevity. While proximal femoral replacement (PFR) would be an easier solution, they are associated with poorer hip scores and decreased prosthesis survival rates which are not ideal while managing young patients. We present a case of proximal femoral bone loss in a young female - following multiple failed osteosynthesis surgeries aimed at addressing a pathological sub-trochanteric fracture - managed successfully with a circumferential allograft during total hip arthroplasty. While there is many literature reporting the use of circumferential allografts during revision hip surgery, this is the first case to the best of our knowledge where we are reporting its successful use in a complex primary hip arthroplasty case. Our successful outcome shows that reconstruction of proximal femoral bone loss using allografts in young patients should be considered prior to use of PFR in them.

Is There a Benefit to Modularity for Femoral Revisions When Using a Splined, Tapered Titanium Stem?

BACKGROUND: Proposed benefits of modularity for femoral revisions in total hip arthroplasty (THA) include more precise biomechanical restoration and improved stability, but this has not been proven with use of a splined, tapered design. This study's purpose is to compare (1) complication rates, (2) functional outcomes, and (3) radiographic measures of subsidence, offset, and leg length discrepancy with the use of modular vs monoblock splined, tapered titanium stems in revision THA. METHODS: We retrospectively reviewed 145 femoral revisions with minimum 2-year follow-up (mean, 5.12 years; range, 2-17.3 years). Patients receiving a modular (67) or monoblock (78) splined, tapered titanium stem for femoral revision were included. RESULTS: There were no statistically significant differences in rates of reoperation (22.3% vs 17.9%; P = .66), intraoperative fracture (9.0% vs 3.8%; P = .30), postoperative fracture (3.0% vs 1.3%; P = .47), dislocation (11.9% vs 5.1%; P = .23), or aseptic loosening (4.5% vs 6.4%; P = .73) between the modular and monoblock cohorts, respectively. There were similar results regarding subsidence >5 mm (10.4% vs 12.8%; P = .22), LLD >1 cm (35.8% vs 38.5%; P = .74), restoration of hip offset (-5.88 ± 10.1 mm vs -5.07 ± 12.1 mm; P = .67), and Harris Hip Score (70.7 ± 17.9 vs 73.9 ± 19.7; P = .36) between groups. Multivariate regression showed no differences in complications (P = .44) or reoperations (P = .20) between groups. CONCLUSION: Modular and monoblock splined, tapered titanium stems demonstrated comparable complication rates, functional outcomes, and radiographic parameters for femoral revisions. However, a limited number of patients with grade IIIB or IV femoral bone loss received a monoblock stem. Future investigations are required to determine whether modularity is beneficial for more complex femoral defects.

Revision Total Hip Arthroplasty With a Monoblock Splined Tapered Grit-Blasted Titanium Stem.

BACKGROUND: In revision total hip arthroplasty (THA), proximal femoral bone loss creates a challenge of achieving adequate stem fixation. The purpose of this study was to examine the outcomes of a monoblock, splined, tapered femoral stem in revision THA. METHODS: Outcomes of revision THA using a nonmodular, splined, tapered femoral stem from a single surgeon were reviewed. With a minimum of 2-year follow-up, there were 68 cases (67 patients). Paprosky classification was 3A or greater in 85% of the cases. Preoperative and postoperative Harris Hip Scores (HHS), radiographic subsidence and osseointegration, limb length discrepancy, complications, and reoperations were analyzed. RESULTS: The Harris Hip Score improved from 37.4 ± SD 19.4 preoperatively to 64.6 ± SD 21.8 at final follow-up (P < .001). There were 16 revision procedures-8 for septic indications and 8 for aseptic indications. Subsidence occurred at a rate of 3.0% and dislocation at 7.4%. Limb length discrepancy of more than 1 cm after revision was noted in 13.6% of patients. Bone ingrowth was observed in all but 4 patients (94.1%). At 4-year follow-up, Kaplan-Meier estimated survival was 72.9% (95% confidence interval [CI] 57.0-83.8) for all causes of revision, 86.6% (95% CI 72.0-93.9) for all aseptic revision, and 95.5% (95% CI 86.8-98.5) for aseptic femoral revision. CONCLUSION: Although complications were significant, revision for femoral aseptic loosening occurred in only 3 patients. Given the ability of this monoblock splined tapered stem to adequately provide fixation during complex revision THA, it remains a viable option in the setting of substantial femoral bone defects.

Periprosthetic Femoral Fracture With Broken Implant Insitu: - A Treatment Prospect.

INTRODUCTION: Fractures involving bones containing a component of a prosthetic joint are becoming more common. The causation is multifactorial but most of these injuries are associated with trivial trauma. The options available for operative management of these fractures include internal fixation of the fracture alone, fixation of the fracture with revision of the prosthesis, and reconstruction of proximal femur with either modified impaction bone grafting or proximal femoral replacement. CASE REPORT: We present here a case of periprosthetic fracture Vancouver type B1 with a broken cemented bipolar prosthesis insitu, in which the broken implant was firmly fixed in the proximal fragment and could not be removed following which the whole of the proximal fragment along with the broken implant was removed and replaced by a customized steel long stem cemented mega prosthesis. CONCLUSION: This case is being presented on account of its unusual presentation and fracture pattern. A broken prosthesis along with a periprosthetic fracture is not a common incident. Thus the treatment had to be individualized. Since the prosthesis was well fixed, its broken stem could not be removed from the proximal fragment and so the whole of the proximal fragment along with stem was removed and replaced with a long stem custom made bipolar prosthesis.

Cementless Revision Total Hip Arthroplasty Using Modular Distal Fixation Stem / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to retrospectively evaluate the results of modular distal fixation stem for the proximal femoral deficiency in revision total hip arthroplasty. MATERIALS AND METHODS: Thirty five patients (36 hips) were followed for more than 24 months after the revision total hip arthroplasty using modular distal fixation stem between December 1998 and May 2002. The preoperative diagnoses included 27 cases of aseptic loosening, 7 cases of septic loosening, and 2 periprosthetic fractures. The femoral deficiencies classified according to Paprosky classification: Type II 3 cases, Type IIIA 14 cases, Type IIIB 8 cases, and Type IV 11 cases. RESULTS: The average Harris hip score improved from 39.5 points to 89.4 points. The average subsidence of the femoral component was 1.3 mm (range, 0-10 mm). All 36 hips had stable fixations, which were 30 cases by bony ingrowth and 6 cases by stable fibrous ingrowth. Postoperative complications included 3 cases of posterior dislocation, 1 case of heterotopic ossification, 1 case of deep vein thrombosis, and 1 case of reactivated infection. CONCLUSION: Cementless revision total hip arthroplasty using modular distal fixation stem showed good short-term results in the face of the deficient proximal bony support, and it appears to be a effective surgical option in this difficult revisional total hip cases.

Reconstruction of Proximal Femoral Bone Loss using Autogenous Unicortical Iliac Bone Plate in Revision Hip Arthroplasty / 대한정형외과학회잡지

PURPOSE: Since 1995, we have reconstructed defects of the proximal femoral bone with the autogenous unicortical iliac bone by revision hip arthroplasty. We report the preliminary results of this method. MATERIALS AND METHODS: Among cases of revision hip arthroplasty reconstructed with autogenous unicortical iliac bone graft between March 1995 and December 1997, we studied 45 cases, which had been followed for more than 2 years. The loss of femoral bone was classified using AAOS classification. Twenty four cases belonged to level 1, segmental type and 21 cases belonged to level 1, segmental with level 2 cavitary type. We documented the healing process of grafted bone by simple radiography every 6 months and evaluated clinical results by Harris scoring. RESULTS: The average Harris score improved from 67.2 to 79.5. Radiological union was found at an average 4.5 months, and complete union at an average 19 months. There were 2 cases of loosening, 4 prolonged pain on the bone-harvested site, 3 trochanteric nonunion, one sciatic nerve palsy and one pulmonary embolism. CONCLUSION: Small sized defects of the proximal femur are reconstructed satisfactorily by using autogenous unicortical iliac bone graft in revision hip arthroplasty.