Bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis: seventy eight revisions using bone allografts with or without metal reinforcements

Minimum 10 years clinical and radiological outcomes of acetabular revisions of total hip arthroplasties with tricalcium phosphate/hydroxyapatite bone graft substitute

BACKGROUND

Aseptic loosening is the most frequent indication for revision of total hip arthroplasty. Revision arthroplasty of acetabular component is a challenge for every surgeon because they have to simultaneously deal with the reconstruction of bone defects, adequate implant geometry and stable fixation. Allografts are the most frequently used materials in reconstruction of bone loss during revision surgeries. Because of an increasing number of revision hip arthroplasties and poor availability of allografts, we decided to use bone graft substitutes in acetabular revisions.

METHODS

Between September 2005 and January 2010, 44 revision arthroplasties in 43 patients were performed with the use of bone graft substitutes for acetabular defect reconstruction in revision of total hip arthroplasty. Acetabular bone defects were classified according to Paprosky. Seventeen hips were classified as IIA, 3 hips IIB, 3 hips IIC, 10 hips IIIA and 11 hips IIIB. Acetabular bone defects were reconstructed with tricalcium phosphate/hydroxyapatite bone graft substitute - BoneSave. Clinical and radiological examination was performed after 3 months, 1 year and then annually. Harris hip score was used for clinical evaluation. Survival analysis was performed with Kaplan-Meier method with aseptic loosening as the definition of endpoint.

RESULTS

The average follow-up period is 12 (range from 10 to 15) years. During the follow-up, three patients died after 24 months because of causes not related to surgery. None of the patients was lost to follow-up. The evaluation of clinical results revealed an increase in pre-operative HHS from average 38.3 (range 25 to 55) points to average 86.3 (range 45 to 95) points at the most recent follow-up. Radiographic evaluation showed the migration of one revision cage 12 months after surgery. Revision arthroplasty performed after 14 months revealed the partial incorporation of bone graft substitute. There were not any cases of loosening of revision acetabular cup at the most recent follow up examination in the remaining 39 patients. Bone graft substitute was not absorbed in all of these patients. The survival after 10 years amounted to 97.56%.

CONCLUSION

Bone graft substitute Bone Save may be suitable for acetabular revision surgery, however preoperative bone defect is critical for success and determining of a surgical technique, so this is multifactorial in this challenge surgery.

The quality assessment of the University hospital bone bank in Central Serbia: the second audit after fourteen years

We analyzed the prevalence and predisposing factors for the overall rejection rate after retrieval of 267 fresh femoral head allografts over the past 7 years. The present study aimed to assess the quality system of institutional bone banking that can provide high-standard allografts with a low infection rate. Retrospective analysis of bone banking from June 2013 to December 2019 was conducted on 267 donors and 153 recipients. Of the 267 donated femoral heads, 74 were rejected, giving an overall rejection rate of 27.71%. The leading cause of allograft rejection was the inability to perform serology tests due to donor death; the absence of serological tests itself, and the donor refusal to perform the serology 6-month retest in 42 donors (15.72%). At retrieval, 12 allografts were positive, giving an overall contamination rate of 4.49%. Seven (2.62%) of the 267 allografts failed the blood screening tests. Thirteen allografts (4.86%) were discarded because of suspected damage to the packaging or disuse during surgery. An infection rate of 1.30% was found following transplantation. Over the past 7 years of bone banking, our results show that the overall rejection rate and the allograft-related infection rate correlate with international standards. The leading cause of allograft rejection was the inability to perform serology tests due to donor death and their refusal to perform the serology retests. Besides stringent aseptic allograft handling, donor motivation to participate in bone banking is extremely important for its efficient functioning.

Bone formation at Ti-6Al-7Nb scaffolds consisting of 3D honeycomb frame and diamond-like carbon coating implanted into the femur of beagles

We fabricated Ti-6Al-7Nb bone scaffolds with 5 mm diameter and 20 mm length comprise of a three-dimensional (3D) honeycomb frame structure of truncated octahedra created by selective laser sintering 3D printing. The honeycomb frame was then coated with 0.1 μm thick diamond-like carbon (DLC) to increase biocompatibility. A round rod of Ti-6Al-7Nb alloy (ASTM F1295) was as a control material. They were implanted into the femur bones of beagles to evaluate bone morphometrics and to investigate changes in the transcriptome of the new bone tissue using DNA microarray analysis and real-time polymerase chain reaction (PCR). In the present report, the 3D honeycomb material with and without DLC film consisting of a-C:H is referred to as 3D_a-C:H and 3D_non, respectively. At 3 weeks after implantation, the 3D_non had more contact between the new and artificial bones compared with the control, and the 3D_a-C:H had more contact between the new and artificial bones compared with the control and 3D_non. Furthermore, 3D_a-C:H showed even more new bone compared with the control and 3D_non. At 8 weeks after implantation, more appeared lamellar bone with the 3D_a-C:H implant than those with the control and 3D_non. The real-time PCR results at 1 week of implantation revealed higher expression levels of VEGF, RANKL, and NOTCH2 expression with 3D_a-C:H than with 3D_non and control. As a result of real-time PCR at 2 weeks of implantation, OPN and CTSK expressions were found to be higher with 3D_a-C:H and 3D_non than that with the control.

Acetabular reconstruction with a reinforcement device and bone grafting in revision arthroplasty-a mean five years of follow-up

PURPOSE

To evaluate the clinical and radiological outcomes of acetabular reconstruction using a reinforcement device (RD) in combination with bone grafting in Paprosky type 2 and 3 acetabular bone defects.

METHODS

Morselised bone grafts were used to fill cavitary defects and a structural graft placed in the superior part of the acetabulum in cases of cranial bone defects, with a proximally fixed RD (Protetim, Hódmezővásárhely, Hungary) implanted in all cases. Construct stability, device positioning, hip centre of rotation and medial acetabular wall thickness were evaluated radiologically. Survival rates were estimated with aseptic loosening and revision for any reason as endpoints.

RESULTS

The 28 patients (29 hips) were followed for 4.8 ± 2.7 years (range, 2-10.4 years). Hip centre of rotation was lowered in all cases, with no significant differences between the mean values obtained post-operatively and at the last follow-up. Medial acetabular wall thickness and RD abduction angle were maintained up to the last evaluation. Bone grafts integrated by two years post-operatively in the majority of cases. Kaplan-Meier survival rates were 85.2 % and 82.1 % for the two endpoints at ten years.

CONCLUSIONS

Acetabular reconstruction using a proximally fixed RD in combination with bone grafting offered good mid-term results in the treatment of acetabular bone defects. In cases of severe bone loss, the structural allograft allowed placement of the RD with ischial contact, rendering survival rates similar to RDs with both iliac and ilioischial fixation. The technique was successful in restoring and maintaining medial acetabular bone stock and construct stability for up to ten years.

Bone stock in revision femoral arthroplasty: a new evaluation

PURPOSE

The purpose of this study was to finalize a method allowing a qualitative and numerical evaluation of the bone stock and to confirm its reproducibility, to verify the relationship between the secondary bone stock value and the functional results, and to determine the main factors influencing the value of the bone stock.

METHODS

A clinical and radiological evaluation was performed in a group of 150 revisions of total hip replacements according to a new method taking into account cortical bone thickness, bone density and bone defects.

RESULTS

Interobserver reproducibility was evaluated at an average of 0.6 and intra-observer reproducibility was considered good at 0.8. Between the initial bone stock and at the last follow-up, no significant difference was noticed. For secondary bone stock considered as "very good or good", the gain was +38.1 points versus +29.9 points for patients evaluated as "average or poor" (p < 0.0001). Between the initial bone stock assessment and at last follow-up, a significant relation was found in numerical values for the global type of primary fixation and in the presence of osteopenia (p < 0.0001).

CONCLUSIONS

Deficient secondary bone stock can result in less favourable functional results. The numerical scores confirm the importance of strategic choices during surgery in order to manage bone stock preservation.

Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty

PURPOSE

The procedure of bone allografting associated with a reinforcement device is widely used for acetabulum revision. However in absence of biologic fixation of the allograft, failure of the reconstruction may occur. We made the hypothesis that it would be possible to load these grafts with bone marrow derived mesenchymal stem cells (MSC) to rescue the osteogenic capacity of an allogenic dead bone and therefore enhance incorporation of allografts with the host bone and decrease the number of failures related to the allograft.

METHOD

We identified 60 patients who had undergone acetabular component revision for aseptic failure of cemented implants associated with massive periacetabular osteolysis and Paprosky type 3A or 3B classification (without pelvic discontinuity) between 1996 and 2001. The study group of 30 patients received MSCs in the allograft and at the host graft junction. The average total number of MSCs received by each patient was 195,000 cells (range 86,000-254,000 cells). The control group of 30 patients had no MSCs in the allograft. Patients were matched for the size of periacetabular osteolysis (Paprosky type 3A or 3B). We compared the evolution of the allografts and evaluated cup migration and revision of the hips as end points at a minimum of 12 years or until failure.

RESULT

Better radiographic graft union rates and less allograft resorption were observed with allografts loaded with stem cells. Allograft resorption was significantly decreased in the group with allograft loaded with MSCs (1.2 cm(2) -range 0-2.3 cm(2)-of resorption on radiographs in the group with MSCs; versus 6 cm(2), range 2.1-8.5 cm(2) in the group without MSCs). The rate of mechanical failure was highest (p = 0.01) among the 30 patients with allograft without stem cells (9/30; 30 %) compared with no failures for patients with allograft loaded with stem cells. Revision of the cup was necessary in nine patients in the control group. No revision was performed in the 30 patients of the study group with MSCs.

CONCLUSION

For acetabular defect reconstruction, loading the allograft with MSCs has resulted in a lower rate of failure as compared with allograft without MSCs.

Acetabular impaction bone grafting in total hip replacement

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Systematic review on outcomes of acetabular revisions with highly-porous metals

PURPOSE

The purpose of this study was to systematically review the literature and report the clinical and radiographic outcomes of highly-porous acetabular cups in revision settings.

METHOD

A literature search of four electronic databases of EMBASE, CINAHL-plus, PubMed, and SCOPUS yielded 25 studies reporting the outcomes of 2,083 revision procedures with highly-porous acetabular components. There was lack of high quality evidence (level I and level II studies) and only two studies with level III evidence, while the remainder were all level IV studies. In addition, a majority of the studies had small sample sizes and had short to mid-term follow-up. The mean age of the patients was 65 years (range, 58-72 years) and the mean follow-up was 3.6 years (range, two to six years). Outcomes evaluated were aseptic survivorship, Harris hip scores, migration rates, incidence of peri-acetabular radiolucencies and radiographic restoration of the hip centre.

RESULTS

The mean aseptic survivorship was 97.2% (range, 80-100%). The Harris hip scores improved from a mean pre-operative score of 42 points, (range, 29-75 points), to a mean postoperative score of 79 points (range, 69-94 points). The mean incidence of cup migration and prevalence of peri-acetabular radiolucencies was 2.4% (range, 0-8.8%) and 4.6% (range, 0-19%), respectively, at final follow-up. The vertical hip centre-of-rotation was restored significantly from a mean of 39.2 mm (range, 27.6-50 mm) pre-operatively, to a mean of 24.1 mm (range, 7.4-47 mm), postoperatively.

CONCLUSION

The short-term clinical and radiographic results of highly-porous metals in revision hip arthroplasty are excellent with a low rate of loosening in the presence of both major and minor bone loss.

Total hip arthroplasty revision in elderly patients

In the last years, the number of total hip arthroplasty is increased both in young patients and elderly with a poor bone quality due to extension of surgical indications. According to this trend, also revision surgery showed a growth of its number, especially in elderly patients, because of implant loosening, failed osseointegration of prosthetic components, errors in biomechanical restoration and infections. The aim of this study is to analyze life quality improvement through evaluation of articular functionality and postoperative pain, and to examine osseointegration of implant components with periprosthetic bone. During total hip arthroplasty revision, the orthopedic surgeon often has to face complex cases, especially in elderly patients with a preexisting status of poor bone quality and sarcopenia. In these cases, a correct planning and a surgical procedure well-executed are able to ensure a good outcome that led to pain relief and functional recovery. Furthermore anti-osteoporotic therapy surely represents a useful resource both in primary total hip arthroplasty and in revisions, mainly for elderly patients with a poor bone quality.