Even "Cementless" Surgeons Use Cement

BACKGROUND

Patients presenting with hip arthritis have huge variability in anatomy, bone quality, and functional expectation. These can contribute to a varying degree of complexity on both the femoral and acetabular sides. Surgeons should be aware of all the various options in fixation, bearing surface, and surgical technique.

METHODS

In this article, based on a presentation given at the recent American Association of Hip and Knee Surgeons meeting in Dallas, we will discuss why and how cemented fixation can, and indeed should, be considered when making decisions regarding how a primary, complex primary, or revision hip arthroplasty should be performed.

RESULTS

We will review the evidence, surgical technique, and indications for cemented fixation in primary and complex primary surgery. In addition, we will discuss the potential benefits at revision of previous cemented fixation.

CONCLUSION

We hope to support the concept that even cementless surgeons should also use cement.

A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Aims

The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported.

Materials and Methods

A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database.

Results

A total of 22 studies were included based on the eligibility criteria, including 343 B2 fractures and 167 B3 fractures. The mean follow-up ranged from 32 months to 74 months. Of 343 Vancouver B2 fractures, the treatment in 298 (86.8%) involved revision arthroplasty and 45 (12.6%) were treated with internal fixation alone. A total of 37 patients (12.4%) treated with revision arthroplasty and six (13.3%) treated by internal fixation only underwent further re-operation. Of 167 Vancouver B3 fractures, the treatment in 160 (95.8%) involved revision arthroplasty and eight (4.8%) were treated with internal fixation without revision. A total of 23 patients (14.4%) treated with revision arthroplasty and two (28.6%) treated only with internal fixation required re-operation.

Conclusion

A significant proportion, particularly of B2 fractures, were treated without revision of the stem. These were associated with a higher rate of re-operation. The treatment of B3 fractures without revision of the stem resulted in a high rate of re-operation. This demonstrates the importance of careful evaluation and accurate characterisation of the fracture at the time of presentation to ensure the correct management. There is a need for improvement in the reporting of data in case series recording the outcome of the surgical treatment of periprosthetic fractures. We have suggested a minimum dataset to improve the quality of data in studies dealing with these fractures. Cite this article: Bone Joint J 2017;99-B(4 Supple B):17–25.

Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture

Hip fracture is associated with considerable morbidity and mortality and occurs in an elderly and infirm group of patients. Periprosthetic fracture after hip hemiarthroplasty is a serious complication. In this study, we have reviewed our experience of this injury. The outcome measures used were fracture union, mortality, infection and requirement for further surgery.

METHOD

We identified a cohort of 79 patients who sustained periprosthetic fractures after hip hemiarthroplasty from a prospective hip fracture database of 8354 patients (3611 were treated with hemiarthroplasty). Seventy-two percent were female and the mean age was 86 years at time of periprosthetic fracture.

RESULTS

Sixty-two fractures occurred around uncemented prostheses (Austin Moore n=61); the remainder occurred around cemented prostheses. The mean time from hip fracture surgery to periprosthetic fracture was 35 months (median time 5 months). Fractures were classified according to the Vancouver system. Fifteen percent (n=12) were type A fractures, 26% (n=21) were type B1 fractures, 41% (n=32) were type B2 fractures, 9% (n=7) were type B3 fractures and 9% (n=7) were type C fractures. Twenty-eight patients underwent open reduction internal fixation (ORIF), 36 required revision surgery, one required fixation and simultaneous revision and 14 were treated non-operatively. Eleven percent (n=9) died within 1 month of periprosthetic fracture, 23% had died by 3 months, 34% by 1 year and 49% by 2 years. Nineteen patients (24%) died before fracture union had occurred. Fracture union occurred in 97% of the remaining cases (58/60). Two patients developed nonunion requiring revision surgery (3%), and three patients developed deep infection requiring debridement (4%), one patient had an infection at the time of the periprosthetic fracture requiring a planned two-stage revision, one patient sustained a second periprosthetic fracture and two patients underwent superficial wound debridement (3%). The incidence of periprosthetic fracture at our institution since 1999 is 1.7% (62 of 3611 patients). The incidence rate after uncemented Austin Moore stem was 2.3% (54/2378) and cemented Exeter stem was 0.5% (4/812); Fisher's exact test p=0.004.

CONCLUSIONS

This article reports satisfactory outcomes in this complex group of patients. We have established the incidence of 1.7%, with relatively low rates of nonunion, infection and other complications. The mortality rate has been established, and survivorship analysis has identified an increased rate of fracture around the Austin Moore prosthesis.

Two-stage uncemented revision hip arthroplasty for infection

We treated 50 consecutive patients with infected total hip arthroplasties according to a standard protocol. Previous surgery to eradicate the infection had been attempted in 13 patients and discharging sinuses were present in 20. Aspiration arthrography was routinely carried out before our interventions.

The first stage was a meticulous removal of all foreign and potentially infected material. Samples were taken for culture and a thorough lavage carried out. Antibiotic-loaded beads were placed in the femoral shaft and an antibiotic-loaded cement ball in the acetabulum. At the second stage an uncemented arthroplasty was introduced. Bone allograft was used in 18 patients. The interval between procedures was usually three weeks, but this was extended if the wound was slow to heal or there was extensive bony destruction. Appropriate antibiotics were given for three months.

At a mean follow-up of 5.8 years the rate of reinfection was 8% (4 patients). Two of these patients have had another, successful, two-stage revision. At this medium-term review, a satisfactory clinical and radiological outcome was obtained in all except two patients.