Two-stage revision surgery for hip prosthesis infection using antibiotic-loaded porous hydroxyapatite blocks

Background

Infection of a hip prosthesis is one of the most severe complications encountered in orthopedic practice. Two-stage reconstruction using an antibiotic-impregnated cement spacer has become a popular procedure for the treatment of this condition. However, there are some disadvantages with the use of antibiotic-loaded cement, including low biocompatibility, a very low release ratio, and the possibility of thermal damage to the antibiotic. We have developed an effective drug delivery system for osteomyelitis in which porous hydroxyapatite (HA) blocks are loaded with an antibiotic by the vacuum method. We report here a modification of this delivery system applied for the first stage of two-stage reconstruction surgery against infected hip prosthesis.

Patients and methods

Eight consecutive patients who developed hip prosthesis infection underwent two-stage revision total hip arthroplasty (THA) using antibiotic-loaded porous HA blocks prepared by the vacuum method. Thorough debridement and insertion of antibiotic-loaded HA blocks was performed in the first stage, followed by conversion to THA after eradication of infection in the second stage.

Results

The mean interval between the stages was 16.8 weeks. There were no complications related to the use of the antibiotic-loaded HA blocks. The patients were followed up for an average of 49 months with no evidence of recurrent infection. The mean Japanese Orthopedic Association hip score improved from 45.1 before surgery to 79.6 at the latest follow-up.

Interpretation

This simple approach utilizing antibiotic-impregnated HA blocks prepared by the vacuum method is considered to be effective for treatment of hip prosthesis infection.     

Similar outcomes between two-stage revisions for infection and aseptic hip revisions

Purpose

Two-stage revision hip arthroplasty using an antibiotic-loaded spacer is the most widely performed procedure for infected hip arthroplasties. The clinical outcome of this type of surgery compared with aseptic joint revision with exchange of femoral and acetabular components is still controversial due to the relative lack of medium- to long-term follow-up. Therefore, we analysed clinical and radiological outcomes of septic two-stage revisions compared with aseptic hip revision surgeries.

Methods

In this retrospective study we assessed 82 consecutive patients who underwent two-stage revision for septic total hip (45 patients) or one-stage aseptic revision arthroplasty (37 patients). The average follow-up was 53 months for the aseptic group and 55 months for the septic group. For clinical evaluation, we used the Harris Hip Score (HHS) and the Merle d’Aubigné and Postel score. The postoperative pain level was determined with the visual analogue pain scale.

Results

The surgeries were performed 124 months (aseptic group) and 119 months (septic group) after primary total hip arthroplasty on average. The main indications for aseptic revision surgeries were aseptic loosening (96 %), dislocation (2.2 %), and periprosthetic fracture (2.2 %). In the clinical outcome patients achieved 75.5 points in the aseptic group and 73.4 points in the septic group in the Harris Hip Score. The Merle d’Aubigné and Postel Score revealed 12.5 points for the aseptic group and 13.1 points for the septic group. Mean level of persisting pain was 0.8 (aseptic group) and 0.4 (septic group) on the visual analogue scale (VAS). Overall survival in the aseptic group was 85.6 % at 9.8 years 82.7 % at 10.1 years for the septic group, with a repeat revision rate of 8.1 % and 6.7 %, respectively.

Conclusions

Performing aseptic acetabular and femoral revision hip arthroplasty showed equal clinical outcomes in relation to septic two-stage revision hip surgeries. Our results showed a tendency for better outcome in comparison with the information given in the literature for septic and nonseptic exchange arthroplasties, including a lower rate of re-revisions.

     

Total hip replacement arthroplasty with Mallory-Head system—minimum ten-year follow-up results

Purpose

The purpose of this study was to assess the clinical and radiographic results of a total hip arthroplasty with the double tapered Mallory-Head system.

Methods

The clinical and radiographic results of a consecutive series of 81 total hip replacements in 75 patients were reviewed 10–15?years (average 11.4?years) postoperatively. The patients’ underlying conditions were avascular necrosis in 46 hips (57?%), osteoarthritis in 12 hips (15?%), RA in nine hips (11?%), and others. Clinical results were evaluated based on the modified Harris hip score and modified Merle d’Aubigné-Postel score. A radiographic analysis was performed.

Results

The average modified Harris hip score improved from a preoperative score of 56 points to a postoperative 92 points. The average modified Merle d’Aubigné-Postel score was 15 points at the latest follow up, and 55 hips (68?%) were classified as the clinical grades of excellent or good results. One acetabular component was revised because of loosening, and one was revised for recurrent dislocation.

Conclusion

The clinical and radiological evaluations of the total hip replacements using the Mallory-Head system showed good results.     

Two-stage revision for infected total knee arthroplasty: our experience with interval prosthesis

Introduction

To review our practice of performing two-stage revision for infected total knee arthroplasty using articulating interval prosthesis and to compare the incidence of the recurrence of infection and re-operation rate in patients undergoing two-stage revision as planned with the group of patients who choose not to proceed to the second stage.

Method

This study is a retrospective review of 60 consecutive patients undergoing a two-stage revision for infected total knee arthroplasty using articulating interval prosthesis. All cases managed by a single surgeon using a uniform peri-operative protocol, and short-course parenteral antibiotic therapy.

Result

Thirty-four patients (57 %) (Group 1) underwent the two-stage revision as planned. However, twenty-six patients (43 %) (Group 2) opted not to have a second-stage procedure as the first-stage and interval prosthesis had eradicated the infection, resolved the pain and achieved good functional outcome. There were five cases of recurrent infection in the 60 patients (8 %) at a mean follow-up 5 years. In those completing the two-stage revision, two patients had recurrent infection. Of the patients who retained the interval prosthesis, there were three recurrent infections. There was no statistically significant difference between the groups in terms of recurrence of infection or re-revision.

Conclusion

Two-stage revision with interval prostheses represents a safe and reliable method of treating infected knee prosthesis; however, there may be a role for one-stage revision in selected cases.     

Management of severe periacetabular bone loss combined with pelvic discontinuity in revision hip arthroplasty

Purpose

Revision of failed total hip arthroplasty with massive acetabular bone loss resulting in pelvic discontinuity represents a rare but challenging problem. The objective of this study was to present short to mid-term results of revision total hip arthroplasty with a custom-made acetabular implant in a consecutive series of patients with pelvic discontinuity.

Methods

We retrospectively reviewed 18 consecutive patients with massive acetabular bone loss (Paprosky Type 3B) resulting in pelvic discontinuity reconstructed with revision total hip arthroplasty using a custom-made acetabular component. The prosthesis was created on the basis of a thin-cut 1-mm computed tomography (CT) scan of the pelvis. Initial stability of the implant was obtained by screw fixation. Harris hip score and sequential radiographs were used to evaluate the clinical and radiographic results.

Results

At an average follow up of 30 months (range 17–62 months) 16 of 18 (88.9 %) custom-made implants were considered radiographically stable without signs of acetabular migration of more than 2 mm in the horizontal or vertical direction, implant rotation or screw breakage. Complications included two periprosthetic joint infections treated with explantation of the implant. Three patients had recurrent dislocations postoperatively. The mean Harris hip score improved from 28?±?12 points preoperatively to 69?±?13 points at the time of last follow up.

Conclusion

Treatment of acetabular bone loss and pelvic discontinuity with a custom-made acetabular component can provide a durable solution with good clinical and radiographic results.     

Zementfreier Femurschaftwechsel mit einem modularen Hüftendoprothesenrekonstruktionsschaft

Background

In most cases, loosening of a prosthesis stem is accompanied by periprosthetic osteolysis. This article presents the short-term clinical and radiological results after revision of total hip arthroplasty (THA) with bone substance deficiencies using a modular noncemented femoral stem system (LINK MP).

Patients and methods

Between March 2003 and November 2005, 91 LINK MP modular revision stems were implanted in 90 patients. Eighty-one patients (51 stem revisions, 24 revisions of stem and shell, and six reimplantations after a Girdlestone situation) were available for prospective clinical and radiological evaluation at an average follow-up time of 16.7±6.5 (6–36) months. The average patient age at revision was 67.2±10.5 (31–87) years.

Results

Bone defects in the proximal femur were evaluated according to the Paprosky classification and showed type 2 in five cases, type 3A in 73 cases, and type 3B in three cases. The Merle d’Aubigné score increased significantly from 10.4±2.3 (4–15) preoperatively to 14.7±2.2 (9–18) at the latest follow-up (p<0.001). Migration analysis in conventional radiographs revealed an average stem subsidence of 3.4 mm. Thirty-one intraoperative and postoperative complications were noted in 28 (34.5%) patients.

Conclusion

After a short-term follow-up, the modular noncemented femoral stem system LINK MP was shown to be a reliable tool for revision of THA with bony defects of the proximal femur. Our results are comparable to those for other modular noncemented revision stems. As expected, complication rates were higher than with primary THA.     

Biologisch azetabuläre Defektrekonstruktion beim Hüftendoprothesenwechsel mittels „Impaction Grafting“ und azetabulärem Rekonstruktionsring

Objective

Management of acetabular bone defects Paprosky types IIa and IIb in revision hip arthroplasty by rebuilding the bone stock using impaction bone grafting, primary stable reconstruction with an acetabular reconstruction ring, and restoring the hip center of rotation to its anatomical position.

Indications

Acetabular segmental or combined structural defects in the superior acetabular dome with superior/lateral hip center migration with intact anterior and posterior columns (Paprosky types IIa, IIb).

Contraindications

Acute or chronic infections, severe acetabular bone defects preventing adequate anchorage of the prosthesis—particularly destruction of the posterior column.

Surgical technique

Modified transgluteal, lateral approach to the hip joint. Removal of the loose acetabular component. Complete circumferential exposure of the acetabular rim, while maintaining mechanical stability of the remaining bone. Preparation of the homologous spongiosa chips and reconstruction of the acetabular defect in impaction grafting technique. Implantation of the acetabular reconstruction ring and primary stable fixation with cancellous screws in the acetabular dome. Cemented fixation of a polyethylene inlay.

Postoperative management

Mobilization on 2 underarm crutches from postoperative day 1. Partial weight bearing with 20 kg for 6 weeks postoperatively. If plain radiographs show unchanged seating of the prosthesis after 6 weeks, loading can be increased by 10 kg/week until full weight bearing is achieved; thrombosis prophylaxis is continued throughout. Limitation of hip flexion to 90° during the first 6 weeks, and no adduction and forced external rotation to avoid dislocation. Avoidance of sports involving jumping and axial impact loading for 12 months. Radiologic checkups after 3, 6, and 12 months and, thereafter, every 2 years.

Results

Analysis between 2008 and 2011 involved 22 consecutive patients with a total of 23 prostheses; the mean follow-up was 38?±?11 months. Compared to the preoperative evaluation, follow-up yielded a significant improvement in the average Harris Hip Score (82.2?±?8.7 vs. 44.7?±?10.7) and the Merle d’Aubigné Score (14.6?±?1.9 vs. 7.5?±?1.3). Radiological solid osseointegration of the cup was observed in 21 cases; partial radiolucent lines were seen in 2 cases (9?%) in the zones I–III delineated by DeLee and Charnley. In 21 cases (91?%) radiographs confirmed no measurable migration or displacement of the acetabular component and the bone graft was determined to be incorporated on the basis of osseous consolidation within the grafted area in 20 cases (87?%). During follow-up 3 prosthesis (13?%) required revision.     

Medium-term outcomes of the S-ROM modular femoral stem in revision hip replacement

Introduction

The objective of this study was to analyse results achieved with the S-ROM modular stem in revision surgery.

Materials and methods

A retrospective observational study was conducted from 2007 to 2015 including 51 patients who had a follow-up of ≥?2 years and complete medical history. The mean age was 66.5 years old (34–87). The main reason for revision was aseptic loosening (38 cases, 74.5%), followed by infection (10, 19.6%), instability (2, 3.9%) and an adverse reaction associated with a metal-on-metal hip implant (1, 2%). Using the Paprosky classification, there were 22 cases of type I (43.1%), 27 of type II (52.9%) and 2 of type IIIA (4%). At the end of the follow-up, radiological parameters were assessed using Engh’s criteria. Pre- and postoperative clinical status was assessed using the Harris Hip Score, a visual analogue scale and the Merle D’Aubigné score.

Results

The mean follow-up period was 5.7 years (2–10). The mean Harris Hip Score improved from 45.5 points (22–65) to 85.8 (55–100) (p?<?0.001), and the final mean Merle D’Aubigné scores were 5.2, 4.6 and 5.6 for pain, ability to walk and mobility, respectively. Osseointegration was confirmed in all except one patient with fibrous non-union. No aseptic loosening has been recorded. Postoperative complications were deep infection in four cases (7.8%) and dislocation in three (5.9%).

Conclusion

This study indicates good medium-term outcomes using a modular hip replacement system with porous-coated proximal sleeves in revision surgery in patients with Paprosky type I and II defects.

     

Lesser trochanteric osteotomy in total hip arthroplasty for treating CROWE type IV developmental dysplasia of hip

Purpose

The study was designed to evaluate the efficacy and safety of lesser trochanteric osteotomy for femoral shortening in total hip arthroplasty in treatment of 28 cases of CROWE IV developmental dysplasia of the hip (DDH).

Methods

Patients underwent progressive femoral shortening at the level of lesser trochanteric to make reduction possible into the anatomical acetabulum in all hips. The results were collected and evaluated clinically and radiographically.

Results

The mean follow-up period was 55.3 months. The average postoperative leg length discrepancy was eight millimetres for unilateral THA patients. A modified Merle d’Aubigné scale was improved from 9.3 preoperatively to 15.9 postoperatively. Sciatic nerve palsy was confirmed in two hips which resolved completely in six months. The Trendelenburg sign was positive in two hips at the final follow-up. No revision surgery was required by the final follow-up.

Conclusion

Lesser trochanteric osteotomy proved to be safe and effective in femoral shortening for treatment of CROWE IV DDH without the problem of nonunion at the site of osteotomy.     

Impaction bone grafting for femoral revision hip arthroplasty with Exeter Universal stem in Japan

Objectives

The purpose of the present study was to analyze the retrospective clinical and radiographic results of femoral revision arthroplasties with impaction bone grafting performed by experienced Japanese surgeons.

Patients and methods

We investigated the radiographic and clinical records more than 2?years after the surgery in 99 hips of 93 patients. The average age was 66.3?years (36–84?years) and the average follow-up period was 5.2?years (2–13?years). The Merle d’Aubigné and Postel hip score was used for clinical assessment, and peri-operative fractures were recorded. The survival curve was estimated using Kaplan–Meier method.

Results

The mean Merle d’Aubigné and Postel hip score improved from 9.0 points to 15.2 points at the final follow-up. Augmentations for segmental defect of femoral cortices were undertaken in 55 hips. Metal or strut allograft plates were applied to 9 hips and 21 hips, respectively. Intra-operative fractures or perforations occurred in 20 hips. Re-operations of the femur were undertaken in nine hips including five post-operative femoral fractures. More than 5?mm of subsidence was observed in only 2 hips. The survival rates at 8?years after the operation were 94.8?% with femoral fractures as the end point, 93.1?% with any stem removal or exchange as the end point, and 99.0?% with aseptic stem loosening as the end point, respectively.

Conclusion

The present study showed encouraging mid-term results of impaction bone grafting for femoral revision arthroplasty by experienced surgeons in Japan. Aggressive augmentation of segmental defects and attenuated femoral shafts prevents massive stem subsidence and periprosthetic fracture.     

Porous tantalum shells and augments for acetabular cup revisions

Purpose

The purpose of this study was to evaluate early functional results of revision hip arthroplasty with pelvic bone loss revised with porous tantalum (PT) acetabular components.

Methods

Twenty-five consecutive patients (25 hips) with loose acetabular components after total hip arthroplasty with a minimum of Paprosky IIa pelvic bone loss treated with PT cups with and without modular augments were retrospectively reviewed. Clinical outcomes were assessed using Harris hip score, and Western Ontario and McMaster Universities scores. Mean follow-up was 20.5 months and no patient was lost during follow-up.

Results

The average Harris hip score, and Western Ontario and McMaster Universities scores improved from 40 and 36 preoperatively to 79 and 73 postoperatively, respectively. No statistically significant differences in functional outcome scores were found between the group with moderate (Paprosky IIa, b) and severe (Paprosky IIc or more) acetabular bone loss. At the most recent radiographic evaluation, 24 cups demonstrated no lucent lines and 1 cup had lucent lines but remained well fixed. One cup was revised for traumatic dislocation but was found well fixed at open reduction. There were no septic or aseptic failures in this series.

Conclusion

While awaiting longer-term follow-up studies, trabecular metal components show sufficient primary stability and appear suitable for revision hip arthroplasty with acetabular bone loss.     

Can patients return to high-impact physical activities after hip resurfacing? A prospective study

Purpose

Although the resumption of low-impact sports activities is compatible with total hip arthroplasty (THA), participation in high-impact sports seems problematic, and there is no consensus as to whether it is advisable. The purpose of this article is to evaluate the quality and possibility of resuming high-impact physical activities after hip resurfacing.

Materials

The study was performed in an on-going, single-surgeon, prospective series of 215 resurfacing arthroplasties (RSA). Mean follow-up was 44.1 months (range, 39.1–54.5). Clinical evaluation included the Postel-Merle d’Aubigné (PMA) score, the Oxford hip score, the Harris hip score (HHS), Devane score, and UCLA activity score. A specific questionnaire analysing sports activities was administered to each patient to assess the number and level of physical activities performed (both before the operation and at final follow-up).

Results

In the series of 202 consecutive patients (215 RSA), 50 patients (55 RSA) engaged regularly in at least one high-impact activity before their operation and the onset of pain, 102 patients practised at least one intermediate-impact activity, and the 50 remaining patients undertook only low-impact activities. Harris hip score increased from 44.8 (range, 23–68) before the operation to 97.8 (range, 85–100) at the last follow-up. Mean time to sports resumption after surgery was 14.6 weeks (range, 7–29). The resumption rate was 98 % for sports of any impact level and 82 % for high-impact activities. No osteolysis or implant loosening was observed at follow-up. No revision was performed.

Conclusion

In 2012, no consensus recommendations yet exist for the resumption of sports activities after RSA. Existing recommendations concern only conventional THA. We believe that RSA allows younger and more active patients to resume physical and sports activities without restriction. The rate of return to sports after RSA appears to be excellent and unequalled by conventional hip prostheses. High-impact sports seem to be compatible with hip resurfacing, although no long-term studies have analysed the impact of these activities on wear and/or aseptic loosening.     

The Classic: Functional Results of Hip Arthroplasty with Acrylic Prosthesis

This Classic article is a reprint of the original work by R. Merle d’Aubigné and M. Postel, Functional Results of Hip Arthroplasty with Acrylic Prosthesis. An accompanying biographical sketch on R. Merle d’Aubigné, MD, is available at DOI  10.1007/s11999-008-0571-2. The Classic Article is ©1954 by the Journal of Bone and Joint Surgery, Inc. and is reprinted with permission from Merle d’Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;35:451--475.     

采用抗生素骨水泥假体二期翻修治疗人工髋关节感染

目的探讨采用抗生素骨水泥假体二期翻修治疗人工髋关节感染的疗效。方法自1999年6月至2004年10月,14例初次髋关节置换术后感染患者行二期手术。术前Harris评分平均23分。一期手术中将取出的假体彻底清洗,骨水泥垫临时旷置,关节内引流管引流,术后静脉输入抗生素3周后,改为口服抗生素1个月。二期手术于6个月后进行,植入带抗生素骨水泥型假体。结果14例患者均获得随访,随访时间7～26个月,平均18个月。14例患者术后均无感染复发。术后Harris评分平均70分。结论彻底清创、足够间隔期以及二期手术采用抗生素骨水泥假体是有效控制感染复发的有效措施。     

Primary total hip arthroplasty versus internal fixation in displaced fracture of femoral neck in sexa- and septuagenarians

Background

The optimal treatment of femoral neck fracture in the elderly patient is still under debate. In patients aged 60–80 years, the decision between internal fixation and arthroplasty remains controversial. The primary aim of the present study is to evaluate the functional outcome of patients aged 60–80 years with femoral neck fracture treated with total hip arthroplasty or closed reduction and internal fixation. The secondary aim is to evaluate the incidence of nonunion and avascular necrosis in femoral neck fracture in different age groups.

Materials and Methods

We studied 100 patients affected by displaced fracture of the femoral neck from May 2007 through June 2010. There were 60 men and 40 women with mean age of 66 years. Fifty patients were treated with closed reduction and internal fixation with cannulated screws (group A), and the other 50 patients with total hip arthroplasty (group B). Mean surgical time, blood loss, duration of hospital stay, Harris hip score, complications, and need for reoperation were recorded.

Results

Harris hip score was significantly higher in group B at 3-, 6-, 12-, and 18-month follow-up evaluation. The overall complication rate was 28 % in group A and 32 % in group B, which was not statistically significant. A statistically significant difference was found regarding patients who required reoperation in group A (20 %) compared with group B (no one). The average Harris hip score in the internal fixation group was 90.6 and in the total hip arthroplasty group was 93.7, which was statistically significant (p < 0.05). Our study showed an increased risk for intracapsular hip fracture developing nonunion with older age.

Conclusions

Primary total hip arthroplasty compared with internal fixation appears to be a reasonably safe method of treating displaced fracture of femoral neck in elderly patients. We also concluded that outcome regarding hip function is generally better after total hip arthroplasty compared with internal fixation.

Level of evidence

Level II-Prospective cohort study.     

Uncemented third-generation ceramic-on-ceramic total hip arthroplasty using metal acetabular shell with direct taper locking liner

Background

The ceramic-on-ceramic (CoC)-bearing couple in total hip arthroplasty (THA) was developed to reduce the wear debris and osteolysis. Although the mechanical strength of third-generation ceramic has improved over previous generations, the risk of osteolysis and ceramic fracture is still an important concern.

Methods

We studied 124 uncemented THAs with third-generation CoC-bearing couple implanted between 2000 and 2004. The ceramic liner and head were secured with the direct taper locking mechanism. One hundred and eleven hips were followed-up for minimum of 8 years, with an average follow-up period of 10.1 years (range 8.0–12.8 years). Patients were evaluated with a particular emphasis on the prevalence of the osteolysis and the ceramic fracture.

Results

The survivorship with the end point as implant revision for any reason was 94.9 % (95 % confidence intervals 90.0–99.3 %) at 12.8 years. Revisions were performed because of one ceramic liner fracture, three dislocations, and two deep infections. No radiographic evidence of wear or osteolysis was observed. The preoperative Merle d’Aubigne and Postel hip score increased from 11.6 to 17.1.

Conclusions

Patients, who received third-generation CoC THA had no detectable wear and osteolysis. One ceramic fracture occurred, and the main reason for revision was dislocation.