Resection of the proximal femur during one-stage revision for infected hip arthroplasty

Aims One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. Methods In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. Results Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years’ time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. Conclusion Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678–1685.

Experimental substantiation of the optimal technique for choosing the rotation of the femoral component of the knee endoprosthesis

There was experimental justification of the optimal technique for choosing the rotation of the femoral component of the knee joint endoprosthesis carried out in this research. The individual morphometric characteristics of the femoral condyles and the condition of the collateral ligaments were taken into account in the experiment. The research was conducted on polymer-embalmed preparations of the knee joint, which were divided into three groups, according to the forms of the femoral condyles. We used the standard technique of positioning the resection block and the technique of individual selection of the rotation of the resection block (rotation of the femoral component of the endoprosthesis), based on the assessment of individual morphometric characteristics of the femoral condyles and the state of the auxiliary elements of the knee joint. To implement this surgical approach, typical resections of the proximal condyles of the tibia and distal condyles of the femur were performed, which technically did not differ from the sawdust used in the standard procedure. Then the knee joint was flexed to an angle of 90, Homan retractors were removed and two laminar dilators (Laminar Spreader) were installed in the gap between the proximal tibial sawdust and the posterior parts of the lateral and medial condyles of the femur. This technique provided isometric tension of the fibular and tibial collateral ligaments of the knee joint. Then carried out the positioning of the femoral resection block "four in one". In this case, only the line of the proximal tibial sawdust was used as a reference point, for which the posterior flange of the resection block was positioned parallel to the sawed upper articular surface of the tibia. It is established that the use of the considered technique of positioning the femoral resection block ensures the formation of a uniform flexor gap, regardless of the variant anatomy of the femoral condyles. Thus, there was research a uniform flexion gap in the experiment, which ensured isometric movements in the knee joint and its stability at the control points of the amplitude after implantation of the trial or final components of the endoprosthesis.

Parents and Caregivers Satisfaction After Palliative Treatment of Spastic Hip Dislocation in Cerebral Palsy

Objectives: Pain appearance is one the most common complication of spastic hip disease in children with cerebral palsy (CP). It determines child and caregiver quality of life and life priorities. Reconstruction hip surgery should be considered as a treatment of choice. Some clinical conditions give the inability to perform such a procedure. In our paper, we would like to present four palliative methods of spastic hip dislocation treatment in children with CP.Material: We analyzed four groups of patients treated because of hip pain. Inclusion criteria were pain appearance (visual analog scale-11 or numeric rating scale-11) and hip joint dislocation (migration percentage &gt;80%). All patients were admitted to our department between 2008 and 2018. In the first group, patients were treated only by steroid injections to hip joints; in the second group, patients were recruits after hip interposition arthroplasty with shoulder spacer; in the third group, they were patients after valgus subtrochanteric osteotomy (Schanz); and in the fourth group, these were patients after proximal femoral resection (Castle procedure). The minimal follow-up time was 2 years. The first group consisted of 15 patients (15 hips) with a mean age of 15.5 (8–17) years; the second group, 20 patients (24 hips) with a mean age of 14.2 (9–22.6) years; the third group, 22 patients (24 hips) with a mean age of 13.5 (7–20.5) years; and the fourth group, 10 patients (15 hips) with a mean age of 12.9 (7–17.6) years.Methods: Radiological evaluation was based on a standardized anteroposterior X-ray of the hip joints. Pain severity before surgery and at the last follow-up time was measured by visual analog scale-11. Parents or caregivers were asked about their child's pain during sitting, perineal care, and rest. During the visit, all caregivers were asked about treatment satisfaction (no 0 to max 10) and if they would decide again for the same surgery.Results: In all groups of patients, we observed a decrease in pain complaints. The observed reduction of pain in the first group was from 7.88 (4–10) to 3.08 (0–8) (p = 0.05), but results of injection were observed only for 4 months (2–8), and it has to be repeated (average: two times). In the second group, level of pain was reduced from 4.93 (1–10) to 0.93 (0–5) (p &lt; 0.001); in the third group, from 6.22 (3–10) to 0.59 (0–6) (p &lt; 0.001); and in the fourth group, pain reduces from 5.43 (2–10) to 2.13 (0–5) (p &lt; 0.001). Observed changes concerned mostly sitting position and perineal care. The complication rate was in the second group, 6 of 24 cases of extraarticular ossification; in the third group, 2 of 24 cases with extraarticular ossification, two cases of revision surgery. In the fourth group, two cases needed another femoral resection. In the first group, five patients died during follow-up time, so they were excluded from the study. In the steroid injection group, parents' treatment evaluation was 6.83 (0–10), and only in three cases that they would resign from the treatment. In the hip interposition arthroplasty group, caregivers' evaluation was 7.41 (0–10), and in five cases, parents did not accept the surgery. In the Schanz osteotomy group, parents' evaluation was 5.9 (0–10), and in eight cases, caregivers would not repeat surgery. In the proximal femoral resection group, satisfaction was the highest, 8.3 (3–10), and only two parents would not decide for surgery again.Conclusion: All procedures can be considered as palliative treatment options for pain complain in a spastic hip joint dislocation in children with CP. Steroid injections to the hip joint need to be repeated, and with the follow-up time, it becomes less effective. Steroid injection seems to be the treatment of choice for patients with general anesthesia contraindications. Interposition arthroplasty of the hip joint seems to give better final results, but the highest parents' satisfaction surprisingly was observed in the proximal femoral resection group, but differences were not statistically significant.

Temporal hemiarthroplasty for distal femoral osteosarcoma in early childhood: a case report

Background Prosthetic reconstruction for distal femoral osteosarcoma is challenging for younger children. We herein report a successful case of limb-sparing surgery for a younger patient with distal femoral osteosarcoma requiring osteo-articular resection. Case presentation A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb-salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned. Conclusions This case report provides an example of limb-salvage surgery after distal femoral resection in a small child. The use of a temporary spacer utilizing partial cementation and preservation of the periosteum and induced membrane appears to afford a viable limb-salvage option after distal femoral resection for younger children.

Temporal hemiarthroplasty for distal femoral osteosarcoma in early childhood: A case report

Background: Prosthetic reconstruction for distal femoral osteosarcoma is challenging for younger children. We herein report a successful case of limb-sparing surgery for a younger patient with distal femoral osteosarcoma requiring osteo-articular resection.Case Presentation: A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate, and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned.Conclusions: This case report provides an example of limb salvage surgery after distal femoral resection in a small child. The use of a temporary spacer utilizing partial cementation and preservation of the periosteum and induced membrane appears to afford a viable limb-salvage option after distal femoral resection for younger children.

Temporal Hemiarthroplasty for Distal Femoral Osteosarcoma in Early Childhood: A Case Report

Background: Prosthetic reconstruction for distal femoral osteosarcoma is challenging for younger children. We herein report a successful case of limb-sparing surgery for a younger patient with distal femoral osteosarcoma requiring osteo-articular resection. Case Presentation: A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femurunderwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate, and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned.Conclusions: This case report provides an example of limb salvage surgery after distal femoral resection in a small child. The use of a temporary spacer utilizing partial cementation and preservation of the periosteum and induced membrane appears to afford a viable limb-salvage option after distal femoral resection for younger children.