ObjectiveTo evaluate short-term effectiveness of revision total knee arthroplasty (TKA) with porous-coated metaphyseal Sleeve and MBT implant.MethodsA clinical data of 23 patients (24 knees) who underwent revision TKA by using porous-coated metaphyseal Sleeve combined with MBT implant between March 2015 and April 2017 was retrospectively analyzed. There were 8 males (8 knees) and 15 females (16 knees). The age ranged from 48 to 85 years (mean, 65.4 years). The cause of revision TKA included infection in 14 knees, aseptic loosening in 8 knees, instability in 1 knee, and stiff knee in 1 knee. Bone defects were classified according to the Anderson Orthopaedic Research Institute (AORI) bone defect classification. The femoral defect was rated as type ⅡA in 5 knees, type ⅡB in 17 knees, and type Ⅲ in 2 knees; the tibial defect was rated as type ⅡA in 2 knees, type ⅡB in 20 knees, and type Ⅲ in 2 knees. The mean time between primary TKA and revision TKA was 30.6 months (range, 6-86 months). The preoperative range of motion (ROM) was (56.0±24.9)°. The preoperative Hospital for Special Surgery (HSS) total score was 41.9±14.2; and the pain and function scores were 8.5±5.2 and 33.4±13.5, respectively.ResultsAll patients were followed up 12-39 months (mean, 25.6 months). The mean operation time was 2.2 hours (range, 1.6-2.9 hours). The mean intraoperative blood loss was 580 mL (range, 400-1 000 mL). There were 2 knees (8.3%) of intraoperative fracture associated with Sleeve insertion and 1 knee (4.2%) of acute postoperative infection at 25 days after revision TKA. All incisions healed by first intention. No deep venous thrombosis of lower extremity occurred. X-ray film showed that all implants were stable. At last follow-up, slight discomfort after exercise occurred in 4 knees (16.7%); end-of-stem pain in the tibia occurred in 1 knee (4.2%). The ROM was (114.6±5.1)°, which had significant improvement compared with the preoperative result (t=11.698, P=0.000). The HSS total score (89.0±10.9), pain score (26.9±6.6), and function score (62.1±5.8) also had significant improvement compared with the preoperative results (t=15.616, P=0.000; t=12.522, P=0.000; t=10.076, P=0.000).ConclusionThe porous-coated metaphyseal Sleeve combined with MBT implant in revision TKA has a significant improvement in short-term effectiveness and no signs of implant loosening.
Objective To study the effect of vancomycin-loaded polymethylmethacrylate (VCMPMMA) in the treatment of an experimental hemiprosthetic hip infectionof rabbits. Methods The infected hemiprosthetic hip joints of the rabbits underwent debridement and one-stage revision arthroplasty. Requested by the “fixed” method, 24 rabbits were equally divided into 2 groups: the control group and theexperimental group. The prostheses were fixed with PMMA in the control group, but with VCM-PMMA in the experimental group. X-ray films were taken immediately after operation, and then 4, 8, and 12 weeks after operation. The C reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured before operation, then measured 1, 3, and 7 days after operation, and then 2, 4, 8, and 12 weeks after operation, i.e., they were measured at the above 8 time points. All the rabbits were sacrificed 12 weeks later. The cure rate of the infection was determined by the blood culture for the corresponding bacteria and the Rhodamine-labeled anti-Staphylococcus epidermidisimmune serum staining. Results The X-ray films revealed that6 hemiprosthetic hip joints were dislocated in the control group, but 3 in the experimental group; 58.3% and 16.7% of the hemiprosthetic hip joints were reinfected in the control group and the experimental group, respectively. At 8 weeks in the control group, the serum CRP level decreased to a greater extent than that measured at the time of debridement, but in the experimental group just at 2 weeks （Plt;0.01）. ESR remained elevated in the control group, but at 4 weeks ESR were significantly lowered compared with that measured at the time of debridement（Plt;0.01）. The test results for the pathogenic organisms revealed that the re-infection incidences were respectively 58.3% (7/12) and 16.7% (2/12) in the control group and the experimental group, with the successful revision rates of 41.7% and 83.3% respectively in the above 2 groups. The light microscopy revealed that therewas a heavy infiltration by the inflammatory cells in the reinfected tissues, but there was a proliferation of the fibrocytes in the tissues of the cured patients. Conclusion Onestage revision arthroplasty can significantly promote the control of the hemiprosthetic hip joint infection in rabbits by the use of VCM-PMMA.
Objective To investigate the effectiveness of acetabular revision using jumbo cementless cups. Methods Between May 1996 and May 2011, 35 patients (35 hips) underwent an acetabular revision with jumbo cementless cups, and the clinical data were retrospectively analyzed. There were 12 males and 23 females, with an average age of 64.8 years (range, 47-79 years). The time from hip arthroplaty to revision was 1-15 years (mean, 9.7 years). The causes for revision were aseptic loosening in 32 cases, femoral periprosthetic fracture (Vancouver type B3) in 2 cases, and low toxicity infection in 1 case. According to the classification of acetabular bony deficiencies of the American Association of Orthopedic Surgeon (AAOS), 6 cases were classified as type I, 9 cases as type II, and 20 cases as type III; according to the classification proposed by Paprosky, 5 cases were rated as type II A, 9 cases as type II B, 13 cases as type II C, and 8 cases as type III A. The primary hip arthroplasty cups had an outside diameter of 46-52 mm (mean, 49.6 mm), and the revision cups had an outside diameter of 56-68 mm (mean, 60.4 mm). Harris score was used for hip function evaluation, and X-ray films were taken for imaging evaluation. Results Healing of incision by first intention was obtained in all patients; without infection or neurovascular injury. Prosthetic dislocation was observed in 1 case at 20 days after operation, and was cured after expectant treatment. One patient died at 6 years after operation, and the other 34 patients were followed up 2-14 years (mean, 8.4 years). The Harris score was significantly increased from 46.4 ± 13.4 at preoperation to 90.4 ± 3.6 at last follow-up (t=18.76, P=0.00). The distance between acetabular rotation centre and teardrop line was significantly decreased, and the distance between acetabular rotation centre and lateral teardrop was significantly increased when compared with preoperative ones (P lt; 0.05). Only 1 patient received second revision for aseptic loosening after 10 years; no continuous radiolucent line, prosthetic dislocation, and osteolysis was found, and bony ingrowth was shown in the other patients. Conclusion Jumbo cementless cup for acetabular revision can achieve good effectiveness for having the advantages of simple operation, less bone grafts, and good recovery of the acetabular rotation centre.
ObjectiveTo investigate the short-term effectiveness of three-dimensional (3D) printed trabecular metal pads for Paprosky type Ⅲ acetabular defect in hip revision.MethodsBetween August 2014 and December 2015, the 3D printed trabecular metal pads were used to repair Paprosky type Ⅲ acetabular defects and reconstruct the annular structure of the acetabulums in 5 cases of primary hip revision. There were 3 males and 2 females, aged from 50 to 72 years, with an average age of 66 years. The time from initial replacement to revision was 10 to 18 years, with an average of 14.4 years. The types of prostheses in primary replacement were non-cemented in 3 cases and cemented in 2 cases. The types of acetabular bone defects were Paprosky type ⅢA in 3 cases and Paprosky type ⅢB in 2 cases. The preoperative Harris score was 34.23±11.67. The height of rotation center of affected hip was (38.17±8.87) mm and the horizontal position was (35.62±9.12) mm.ResultsThe operation time was 120-180 minutes, with an average of 142 minutes. The intraoperative bleeding volume was 800-1 700 mL, with an average of 1 100 mL. Five patients were followed up 18-24 months (mean, 21 months). At last follow-up, the Harris score was 79.82±8.70, which was significantly higher than that before operation (t=16.991, P=0.000). At 1 week after operation, the abduction angle of acetabular cup was 38-42° (mean, 39.4 °) and the anteversion angle was 13-18 ° (mean, 14.6°). The height and horizontal position of rotation center of affected hip were (22.08±8.33) mm and (29.03±6.28) mm, respectively, showing significant differences when compared with those before operation (P<0.05); there was no significant difference when compared with those of healthy hip [(28.62±7.73), (27.29±4.22) mm] (P>0.05). During the follow-up, there was no complication such as prosthesis loosening, dislocation, or periprosthetic fracture.ConclusionIn hip revision, 3D printed trabecular metal pads can repair Paprosky type Ⅲ acetabular defect, reconstruct the structure of acetabulum, provide a stable supporting structure for the acetabular cup, reconstruct the relatively normal rotation center of the hip joint, avoid iatrogenic bone loss, and achieve satisfactory functional recovery of the hip. The long-term effectiveness needs further follow-up.
Objective To investigate the medium- and long-term effectiveness of hip revision with SL-PLUS MIA stem in patients with Paprosky typeⅠ-Ⅲ femoral bone defect. MethodsBetween June 2012 and December 2018, 44 patients with Paprosky typeⅠ-Ⅲ femoral bone defect received hip revision using SL-PLUS MIA stem. There were 28 males and 16 females, with an average age of 57.7 years (range, 31-76 years). Indications for revision comprised aseptic loosening (27 cases) and periprosthetic joint infection (17 cases). The Harris hip scores were 54 (48, 60) and 43 (37, 52) in patients with aseptic loosening and periprosthetic joint infection, respectively. The preoperative femoral bone defects were identified as Paprosky type Ⅰ in 32 cases, type Ⅱ in 9 cases, type ⅢA in 2 cases, and type ⅢB in 1 case. Operation time and intraoperative blood transfusion volume were recorded. During follow-up after operation, the hip joint function were evaluated by Harris hip score and X-ray films, the femoral stem survival was analyzed, and the surgical related complications were recorded. Results The operation time of infected patients was 95-215 minutes, with an average of 125.0 minutes. The intraoperative blood transfusion volume was 400-1 800 mL, with an average of 790.0 mL. The operation time of patients with aseptic loosening was 70-200 minutes, with an average of 121.0 minutes. The intraoperative blood transfusion volume was 400-1 400 mL, with an average of 721.7 mL. All patients were followed up 5.3-10.0 years (mean, 7.4 years). At last follow-up, the Harris hip scores were 88 (85, 90) and 85 (80, 88) in patients with aseptic loosening and periprosthetic joint infection, respectively, both of which were significantly higher than those before operation (P<0.05). Radiological examination results showed that the distal end of the newly implanted femoral stem did not cross the distal end of the original prosthesis in 25 cases, and all femoral stems obtained bone fixation. Two cases experienced femoral stem subsidence and 1 case had a translucent line on the lateral side of the proximal femoral stem. When aseptic loosening was defined as the end event, the 10-year survival rate of the SL-PLUS MIA stem was 100%. When treatment failure due to any reason was defined as the end event, the survival time of the prosthesis was (111.70±3.66) months, and the 7-year survival rate was 95.5%. The 7-year survival rates were 94.1% and 96.3% in patients with aseptic loosening and periprosthetic joint infection, respectively. The incidence of postoperative complications was 9.1% (4/44), among which the prosthesis related complications were 4.5% (2/44), 1 case of dislocation and 1 case of infection recurrence. ConclusionHip revision with SL-PLUS MIA stem has the advantages of simple operation and few postoperative complications in the patients with Paprosky type Ⅰ-Ⅲ femoral bone defect, and the medium- and long-term effectiveness is reliable.
Objective To evaluate the mid-term effectiveness of two-stage hip prosthesis revision in the treatment of infection after hip arthroplasty. Methods Between April 2002 and November 2006, 12 cases of infection after hip arthroplasty were treated. There were 5 males and 7 females, aged from 47 to 72 years (mean, 59.8 years). The femoral head arthroplasty wasperformed in 2 cases and total hip arthroplasty in 10 cases. Infection occurred 1 to 67 months after arthroplasty. According to the Segawa classification criteria, infections included type 2 in 1 case, type 3 in 2 cases, and type 4 in 9 cases. The preoperative Harris score was 36.7 ± 6.1. Nine cases had elevated C reactive protein and 10 cases had elevated erythrocyte sedimentation rate. The results of bacterial culture were positive in 8 cases and negative in 4 cases. After the removal of the infected prosthesis and thorough debridement, antibiotic-loaded cement spacers or infected therapeutic temporary prosthesis were used as placeholders, and then the anti-infection treatments were given after operations; two-stage hip prosthesis revisions were performed 3 to 10 months after debridement. Results In 1 patient who failed to control infection after debridement, infection was controlled after the second debridement and the antibiotic-loaded cement spacer as placeholder. Other patients achieved heal ing of incision by first intention, and no compl ication such as deep venous thrombosis and nerve injury occurred. All patients were followed up 3 to 8 years after revision (mean, 5.4 years). During the follow-up, no infection recurrence and joint dislocation occurred. Dull pain was present in 2 cases during activity and mild claudication in 3 cases at last follow-up. The Harris score was 81.6 ± 4.5, showing significant difference (t=52.696, P=0.000) when compared with preoperative score. The X-ray films showed that noprosthesis loosening and obvious subsidence were observed, and bone graft healed. Conclusion The two-stage hip prosthesis revision has good infection control rate and mid-term effectiveness in treatment of infection after hip arthroplasty.
【Abstract】 Objective To evaluate the outcome of two-stage revision for prostheses infection in patients with bone tumor after knee prosthetic replacement. Methods Between August 2003 and August 2010, 22 patients with prostheses infection, who underwent knee prosthetic replacement in limb salvage treatment because of bone tumor, received two-stage revision. There were 11 males and 11 females with an average age of 29.6 years (range, 15-55 years). Prosthetic infection occurred after primary replacement in 20 patients and after revision surgery in 2 patients from 15 days to 89 months after operation. According to Coventry and Fitzgerald classification, type I was found in 3 cases, type II in 15 cases, and type III in 4 cases. The time from infection to admission was 5-47 months (mean, 10.2 months). The results of bacterial culture were positive in 9 cases and negative in 13 cases. Two patients had fever and leukocytosis. In one-stage, the implants and infected tissue were removed, and an antibiotic cement spacer with an intramedullary nail was implanted. In two-stage, a new endoprosthesis was inserted after infection was controlled. Results The C-reactive protein and erythrocyte sedimentation rate before one-stage debridement were significantly higher than those before two-stage revision (P lt; 0.05). All patients were followed up 5-63 months (mean, 23.6 months). Infection was controlled after one-stage debridement in 18 cases (81.8%); two-stage revision was performed in 17 cases, and 1 case refused to receive two-stage revision. Of 17 patients, 1 patient was amputated because of infection at 5 months after revision. Four patients (18.2%) underwent amputation because of failure to control infection after one-stage debridement. The limb salvage rate was 77.3% (17/22). One case of renal cell carcinoma with bone metastasis died of original disease after 1 year and 6 months of operation. The Musculoskeletal Tumor Society (MSTS 93) score was 69.4 ± 12.7 at last follow-up. Conclusion Two-stage revision should be performed in time and it has good results in the treatment of prostheses infection in patients with bone sarcomas after knee prosthetic replacement.
ObjectiveTo explore the correlation between the Barthel index score and other factors with the preoperative occurrence of deep vein thrombosis (DVT) in patients undergoing total hip arthroplasty (THA) revision surgery. MethodsA retrospective analysis was conducted on clinical data from 122 patients who met the inclusion criteria and underwent THA revision surgery between April 2017 and November 2020. Among them, 61 were male and 61 were female, with an age range of 32-85 years (mean, 65.3 years). The reasons for revision included prosthetic joint infection in 7 cases, periprosthetic fracture in 4 cases, prosthetic dislocation in 6 cases, and aseptic loosening in 105 cases. The Barthel index score was 76.4±17.7, with 10 cases classified as level 1, 57 as level 2, 37 as level 3, and 18 as level 4. Univariate analysis was performed on variables such as age, gender, body mass index, Barthel index score, preoperative D-dimer positivity, history of diabetes, hypertension, cancer, cerebral infarction, smoking, and thrombosis in patients with and without preoperative DVT. Furthermore, logistic regression was used to identify risk factors for preoperative DVT in THA revision surgery. The incidence of preoperative DVT was compared among different Barthel index score groups. ResultsPreoperative DVT was detected in 11 patients (9.02%), all of whom had intermuscular venous thrombosis. Among them, 1 had prosthetic joint infection, 1 had periprosthetic fracture, 1 had prosthetic dislocation, and 8 had aseptic loosening. Univariate analysis showed significant differences between the two groups in terms of age, gender, and Barthel index score (P<0.05). logistic regression further revealed that female, age ≥70 years, and Barthel index score<60 were independent risk factors for preoperative DVT in patients undergoing THA revision surgery (P<0.05). The incidence of preoperative DVT in patients with Barthel index scores of levels 1, 2, 3, and 4 were 0 case (0%), 2 cases (3.5%), 3 cases (8.1%), and 6 cases (33.3%), respectively. A significant correlation was found between Barthel index score classification and the incidence of preoperative DVT in patients undergoing THA revision surgery (χ2=10.843, P=0.001). ConclusionIn patients undergoing THA revision surgery, older age, female, and lower Barthel index scores are associated with higher preoperative DVT incidence. For patients with low preoperative Barthel index scores, preoperative thrombosis screening should be emphasized.
Objective To investigate the change of the femoral offset and hip center of rotation (COR) after using Jumbo cups in total hip arthroplasty (THA) revision. Methods The clinical data of 23 patients who underwent THA revision using Jumbo cups between January 2010 and May 2015 were retrospectively analyzed. Morselized bone graft was performed on 8 cases, morselized bone graft combined with structural bone graft on 10 cases. There were 10 males and 13 females, aged 65.4 years on average (range, 51-77 years). The disease duration was 1-24 years (mean, 8.57 years). The reasons for revision included aseptic loosening in 21 cases and periprosthetic infection in 2 cases. The Harris hip score and visual analogue scale (VAS) were 43.04±5.05 and 5.70±0.97 before operation respectively. According to the Paprosky acetabular defect classification, there were 5 cases of type I, 5 cases of type II A, 3 cases of type II B, 6 cases of type II C, and 4 cases of type III A. The X-ray films showed that the femoral offset was (40.65±4.09) mm for normal side and was (44.04±5.08) mm for affected side at preoperation, showing significant difference (t=4.098,P=0.000). Ten patients underwent femoral offset reconstruction (43.48%) but 13 patients did not (56.52%) before operation. The COR was reconstructed in 10 cases (43.48%); COR elevation was observed in 11 cases (47.83%), and COR decline in 2 cases (8.69%) before operation. Results Primary healing of incision was obtained in all patients, with no complication of infection, vascular injury, deep vein thrombosis, dislocation of the joint, or fracture around prosthesis. All the patients were followed up 12-76 months (mean, 22.48 months). The Harris hip score and VAS were 82.09±4.53 and 0.74±0.62 at 1 year after operation respectively, showing significant differences when compared with preoperative scores (t=37.831,P=0.000;t=22.318,P=0.000). The X-ray films showed that the femoral offset was (43.87±3.57) mm for affected side at 1 year after operation, showing no significant difference when compared with preoperative one (t=0.250,P=0.805), but significant difference was found between affected side and normal side (t=5.591,P=0.000). The femoral offset was restored in 16 patients (69.57%) and was not restored in 7 patients (30.43%) after operation. The COR was restored in 15 patients (65.22%) and was not restored in 8 patients (34.78%). Conclusion Using Jumbo cups or combined with morselized or structural bone graft is effective in restoring hip COR and femoral offset at the maximum limit in THA revision, with good short-term outcome and improved stability of acetabular prosthesis.
Objective To explore the effectiveness and failure causes of large-head metal-on-metal total hip arthroplasty (large-head MoM THA). Methods Between March 2007 and May 2010, 159 patients (183 hips) underwent large-head MoM THA, and the clinical data were analyzed. There were 50 females (54 hips) and 109 males (129 hips) with an average age of 50 years (range, 20-78 years). Single hip was involved in 135 cases (left hip in 69 cases and right hip in 66 cases) and double hips in 24 cases. The causes included femoral head necrosis in 74 cases (93 hips), Legg-Calve-Perthes in 1 case (1 hip), osteoarthritis in 18 cases (19 hips), developmental dysplasia of the hip in 17 cases (18 hips), osteoarthritis after hip septic infection in 8 cases (8 hips), traumatic arthritis of the hip in 6 cases (6 hips), femoral neck fracture in 17 cases (17 hips), ankylosing spondylitis in 8 cases (11 hips), rheumatoid arthritis of hip in 9 cases (9 hips), and adult onset Still’s disease in 1 case (1 hip). Before operation, visual analogue scale (VAS) was 6.59±0.87; Harris score was 45.99±8.07. Results Healing of incisions by first intention was achieved, and no operative complication occurred. The patients were followed up 1.2-8.2 years (mean, 6.1 years). Implant failure was observed in 15 cases (17 hips), and the 5-year survival rate of large-head MoM THA was 91.80% (168/183). The causes of implant failure after THA were inflammatory pseudotumor in 4 cases (4 hips), acetabular aseptic loosening in 3 cases (3 hips), osteolysis in 4 cases (5 hips), acetabular aseptic loosening combined with inflammatory pseudotumor in 3 cases (3 hips), and functional disused in 1 case (2 hips). Of them, 9 cases (11 hips) did not receive revision surgery for various reasons, while 6 cases (6 hips) underwent revision surgery at 1.2-5.4 years (mean 3.7 years) after large-head MoM THA. At last follow-up, VAS and Harris score were 1.72±1.48 and 81.37±10.75 respectively, showing significant differences when compared with preoperative scores (t=–35.547，P=0.000；t=33.823，P=0.000). The function was excellent in 44 hips, good in 89 hips, fair in 33 hips, and poor in 17 hips. Conclusion Large-head MoM THA has a high revision rate during mid- and long-term follow-up because of inflammatory pseudotumor, acetabular aseptic loosening, and osteolysis. Early revision can effectively improve the function of the hip and improve patients’quality of life.