Novel custom made composite spacer for first-stage revision total hip replacement in the presence of extensive acetabular/femoral bone loss with abductor deficiency

A two-stage revision total hip replacement (THR) remains the gold standard for treating chronic periprosthetic joint infection. The goals for the first stage are twofold: (1) remove infected tissue/implants, obtaining tissue samples for culture; (2) deliver local antibiotics and maintain hip function with a prosthesis with antibiotic-loaded acrylic cement. With extensive bone loss prefabricated spacers are not sufficient, therefore customised spacers are required. The current technique, coating cephalomedually femoral nail in cement, is complex, time consuming, functions poorly and causes wear debris from excessive friction at the femoral/acetabular articulation. We report a technique to create a custom made composite spacer using a short femoral nail, standard Exeter femoral stem (Stryker), Trident acetabular cup (Stryker) and polymethyl methacrylate (PMMA) bone cement with antibiotics. This technique restores hip biomechanics and gives a stable articulation, even in the presence of abductor deficiency, due to dual mobility bearings.

Anterolateral Bone Window for Revision Broken Cemented Stem of Unipolar Hemiarthroplasty

Background. Fractured stem of the hip prosthesis is well documented in the literature. Although it is rare, it is considered as a challenging problem. Many techniques have been described to solve this problem. Purpose of the Study. Evaluation of the effect of anterolateral bone window for extraction of the cemented femoral stem of hemiarthroplasty in revision total hip replacement. Methods. The study included eight revision hip arthroplasties in eight patients, with a broken stem of cemented (Thompson) hemiarthroplasty, which has been revised by the anterolateral proximal femoral window. All cases received cemented cups and cement-in-cement stems, except one case who received cementless long stem. Clinical follow-up of cases by Harries hip score (HHS) and X-ray. Results. Functional improvement of HHS of all cases, with no signs of loosening, after a mean follow-up period of 1.5 years. Conclusion. Extraction of broken stem is a challenging procedure. Many techniques have been described for revision of cases with a fractured stem of hip prosthesis, but we think that the anterolateral femoral bone window is a reproducible technique due to the characteristics of simplicity, short-time procedure, less invasive, not requiring extra instruments, and can be successful for most patients.

Femoral Revision Total Hip Arthroplasty Performed through the Interval of the Direct Anterior Approach

Background: we report the clinical outcomes for femoral revision total hip replacement (THR) using the Direct Anterior Approach (DAA) interval. Methods: 149 patients (165 hips) with a mean age of 68.9 years (range, 33.2–91.0 years) and a mean follow-up of 4.2 years (1.1–8.9 years) were included. The indication for revision surgery was aseptic stem loosening in 131 (79.4%) hips, periprosthetic fracture in 29 (17.6%) hips, revision for stem malalignment in one (0.6%) hip, and prosthetic failure in four (2.4%) hips. Results: an endofemoral approach was used for 156 hips, and a Wagner transfemoral osteotomy was used for nine hips. An additional cup revision was done in 52 hips (uncemented cup: n = 29; cemented cup: n = 21; acetabular cage: n = 2). The overall complication rate was 14.5% (24 complications). Ten patients (10 hips) were revised (8 cups, 2 liners, 2 stems) with an average time to revision of 6 months (range, 3–23 months). The median preoperative Western Ontario McMasters Osteoarthritis Score (WOMAC) score was 52.5 (Inter Quartile Range (IQR): 33.3), which improved to 27.2 (IQR: 30) postoperatively (p < 0.01). Conclusion: use of the DAA achieved similar results when compared with other surgical approaches in terms of clinical outcomes and complications, including dislocation rate. These results suggest that femoral revision using the DAA interval can be a safe and reliable procedure.

The Survivorship of Revision Total Hip Replacement With Severe Proximal Bone Deficiency Using a Modular Taper Fluted Prosthesis

BackgroundContemporary uncemented femoral revision hip systems have become commonly used over the past decade and have enabled the reconstruction of leg length, offset and anteversionas independent variables through the use of modular junctions. Modular junction failures between the proximal body and distal stem have been described withrevision systems, although this is rare. We sought to identify the survivorship of one revision system in a salvage arthroplasty scenario where no host bone support of the modular junction was present.MethodsFrom a series of 136 patients, 15 patients (16 hips) were identified without host bone support of the modular junction with a mean radiological follow up of over 6 years(76 months +/- 35 months).ResultsThere have been no cases of prosthetic fracture over the follow-up duration, withtwo revisions performed for reasons of aseptic loosening and infection. The mean BMI of the study group was 30.2 with 78% of the cohort classified as overweight or obese.ConclusionIt is well recognised that, host bone support of the modular junction is preferable, however the satisfactory outcomes over the midterm in these complex patients suggests that modular revision systems remain an option.

Fungal Periprosthetic Joint Infection of Hip – Report of 2 Cases

A 72-year old woman had revision unipolar hemiarthroplasty for AMA loosening with vertical split fracture of greater trochanter. This was complicated by PJI, treated with staged arthroplasty with articulated antibiotic loaded cement spacer. Revision of antibiotic loaded cement spacer for dislocation and cable plate fixation of greater trochanter was done. Then the tissue specimen grew Candida ablicans. Fluconazole was given. Repeated debridement and exchange of antibiotic loaded cement spacer was done twice again with amphoteric B and vancomycin added to the cement. Unfortunately, the frozen section was still positive despite the CRP was returned to normal for 1 month. Oral fluconazole was continued. Finally, revision total hip replacement was done 14 months after the initial insertion of antibiotic loaded cement spacer. The patient could manage to walk with frame indoor with no hip pain at 3 year follow-up. Another 80-year old woman had removal of AMA, debridement and antibiotics loaded cement spacer was done for PJI. This was complicated by breakage of the articulated cemented spacer during reduction and later hip dislocation despite of cemented acetabular liner. A total of 3 debridement and antibiotics loaded cement spacer were done. Besides Candida albicans, tissue also grew Enterobacter cloacae and Pseudomonas aeruginosa. Exchange of cement space loaded with gentamicin and voriconazole was done as the 4th reoperation 22 weeks after the debridement and antibiotics loaded cement spacer insertion. Intraoperatively, the patient developed haemorrhagic shock and complicated with myocardial infraction and pneumonia postoperatively and eventually succumbed 12 days after the last operation. The control rate of fungal PJI of only 36% was reported in the literature. The use of systemic and local antifungal agents, surgical treatment strategy and outcomes will be reviewed.

Pseudotumour and Metallosis after Revision Total Hip Replacement. Case Study

Metallosis is a complication of hip arthroplasty. This pathological process contributes to the loosening and dislocation of the prosthesis. This article discusses the case of a 61-year-old patient who reported pressure and pain as well as a palpable subcutaneous lump in the left lower abdomen and groin area. Medical history included total arthroplasty and repeat arthroplasty of the left hip joint, hysterectomy, appendectomy and a laparoscopic fundoplasty. A CT scan and ultrasound showed an unrecognised heterogeneous fluid area raising suspicions of a rumour mass or an old haematoma. After exclusion of gastrointestinal pathology, the patient was referred to the department of trauma and orthopaedic surgery, where a new x-ray of the hip, ultrasound and CT scan were performed and loosening of the prosthesis was ruled out. The pathological tissue was removed surgically through an incision in the groin area. On the basis of intraoperative changes, the pseudotumour was diagnosed as metallosis based. In con­clusion, any suspicion of a pseudotumour requires extensive and accurate evaluation, excluding general surgical causes. Complete surgical removal of the tumour is the only effective method of treatment.