Pseudotumor recurrence in a post-revision total hip arthroplasty with stem neck modularity: A case report

BACKGROUND This unique presentation of hip swelling is only the seventh reported case of pseudotumor recurrence in a non-metal-on-metal total hip arthroplasty(THA)construct.The constellation of patient symptoms and laboratory findings contradict the expected elevated serum metal ion levels associated with the formation of pseudotumor.The presentation,lab trends,and imaging findings contribute to the growing base of knowledge surrounding the effects of corrosion in arthroplasty constructs with stem-neck modularity.CASE SUMMARY A 74-year-old man status post primary THA presented with left hip swelling and elevated serum metal ions five years after implantation of a modular stem-neck prosthesis.The swelling was diagnosed as pseudotumor based on laboratory trends and imaging findings and was treated with revision arthroplasty that completely resolved the initial hip swelling.The patient presented with recurrent hip swelling and recurrent pseudotumor findings on imaging in the same hip four months later.Non-operative management with ultrasound-guided hip aspiration resulted in symptom relief and resolution of the recurrent swelling.After one year of follow-up,the patient had no further recurrences of hip swelling.CONCLUSION This case of post-revision pseudotumor recurrence elucidates attributable patient,surgical,and implant factors with a discussion of diagnostics,management,and prognosis for patients with pseudotumor in non-metal-on-metal arthroplasty constructs.

Management of Severe Femoral Bone Defect in Revision Total Hip Arthroplasty-A 236 Hip,6-14-year Follow-up Study

Summary： This study evaluated the clinical effect of impaction bone graft and distal press-fit fixation for the reconstruction of severe femoral bone defect in revision total hip arthroplasty. A total of 234 patients （involving 236 hips） with Paprosky III and 1V femoral bone defects were treated with the revision total hip arthroplasty from June 1998 to Aug. 2006. Impaction bone graft technique was used for 112 hips, with allogeneic freeze-dried bone as bone graft and SP II as prosthesis. With 124 hips, modular distal press-fit fixation and tapered femoral stem （MP stem） were employed. After the operation, the subjects were followed up on regular basis and results were assessed by using the Harris Hip Score （HHS） and 12-item Short Form Health Survey （SF-12）. Radiolucence, subsidence and loosening were observed and complications, including infection, fracture, dislocation etc. were recorded. A 6-14-year follow-up showed that prostheses failed, due to infection, in 4 patients of impaction bone graft group and that 6 patients in the press-fit fixation group experienced prosthesis failure, with the survival rates for the two techniques being 96.43% and 95.16%, respectively. One-way ANOVA showed that prosthesis survival was significantly associated with surgery-related complications （P〈0.05） and was not related to the type of the bone defects （P〉0.05）. The rate of complications bore significant association with the type of bone defects in the two groups （P〈0.05）. Our study showed that the two revision methods could achieve satisfactory mid-term and long-term results for the reconstruction of severe bone defects. It is of great significance for attaining high prosthesis survival rate to select suitable operation on the basis of the type of bone defect. Careful operative manipulation and post-operative rehabilitation aimed at reducing complications are also important.

Tibial tubercle osteotomy in revision total knee arthroplasty: A systematic review

BACKGROUND Tibial tubercle osteotomy(TTO) is a well-established surgical technique to deal with a stiff knee in revision total knee arthroplasty(RTKA). However, several reports have described potential osteotomy-related complications such as nonunion, tibial tubercle migration and fragmentation, and metalware related pain.AIM To evaluate the literature and estimate the efficiency of TTO in RTKA in terms of osteotomy union, knee mobility and complications.METHODS MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were investigated for completed studies until February 2020. The principle outcome of the study was the incidence of union of the osteotomy. Secondary outcomes were the knee range of motion as well as the TTO-related and overall procedure complication rate.RESULTS Fifteen clinical studies with a total of 593 TTOs were included. The TTO union rate was 98.1%. Proximal migration and anterior knee pain were the most common TTO-related complications accounting for 6.9% and 6.4% of all cases,respectively. However, only 2.2% of cases suffering from anterior knee pain needed hardware removal. Knee flexion was improved from 82.9° preoperatively to 100.1° postoperatively and total knee range of motion was increased from 73.4° before surgery to 97° after surgery. Stiffness requiring manipulation under anesthesia was recorded in 4.6% of cases. No major complications were reported.CONCLUSION The current systematic review supports the use of TTO in RTKA, as it is associated with high union rate, significant improvement in knee motion and low osteotomy-related complication risk that rarely leads to secondary tibial tubercle procedures.

Femoral Head Autograft to the Iliac for Use in Future Revisions of Total Hip Arthroplasty: 15-Year Follow-Up

Introduction: The therapeutic success of total hip arthroplasty (THA) is unquestionable. However, in young patients, it is still a controversial topic, not because of the results obtained, but because of the presumed need for revision of the prosthetics components in the future. Objectives: The present work performs a retrospective study of patients who underwent THA surgery in the past, in which the femoral head was transferred to the iliac for use in future revisions of total hip arthroplasty (autograft), and describes the proposed technique. Methods: The research reviewed 27 patients operated on using the femoral head autograft technique for the ipsilateral iliac in total hip arthroplasty, performed from 1996 to 2005;the study considered medical records, X-rays and CT scan images, and photographs taken at the time of surgery. Results: To date, only two revisions of total hip arthroplasty have been performed, in which the patients have benefited from the technique of autografting of the femoral head. No case evolved with infection or any other type of complication. All inserted grafts are consolidated and integrated with the iliac. Conclusion: The autograft technique is cheap, simple and reproducible, making available large amounts of bone for use in future revisions of total hip arthroplasty in young patients.

Challenges of Anticoagulation in Total Joint Arthroplasty

Aggressive anticoagulation following total joint arthroplaty (TJA) is well known to increase the risk of both wound leakage and hematoma formation. Despite this there are no guidelines for orthopaedic surgeons undertaking major primary and revision surgery in patients with high risk of venous thromboembolic events, who may present with complications directly linked to anticoagulant use. Hence the authors felt the need for this narrative review. They have tried to answer few questions that are commonly faced in clinical practice. Balanced anticoagulation is a difficult task to achieve. The potential consequences of over anticoagulation on the outcome of TJA and revision TJA are live changing and devastating. On the contrary falling short of adequate anticoagulation is fatal leading to recurrent thromboembolic events. Robust risk stratification tools and a multidisciplinary approach are certainly the way forward. There is an urgent need for specialty specific guidelines for managing patient on anticoagulation undergoing TJA, and revision arthroplasty procedures.

Systematic review of single stage revision for prosthetic joint infection

While advanced technology,increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty,prosthetic joint infection still remains one of the leading causes of increased healthcare costs,medical resources and societal burdens in orthopaedic care.Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection.Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates.Here we review the history of single stage revision arthroplasty,discuss the key principles,highlight the indications and contraindications,and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Cemented versus uncemented stems for revision total hip replacement:A systematic review and meta-analysis

BACKGROUND The popularity of uncemented stems in revision total hip arthroplasty(THA)has increased in the last decade.AIM To assess the outcomes of both cemented and uncemented stems after mid-term follow up.METHODS This study was performed following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for systematic reviews and meta-analysis guidelines.Articles were chosen irrespective of country of origin or language utilized for the article full texts.This paper included studies that reviewed revision THA for both cemented or uncemented long stems.RESULTS Three eligible studies were included in the meta-analysis.Analysis was conducted by using Review Manager version 5.3.We computed the risk ratio as a measure of the treatment effect,taking into account heterogeneity.We used random-effect models.There were no significant differences found for intraoperative periprosthetic fractures[risk ratio(RR)=1.25;95%confidence interval(CI):0.29-5.32;P=0.76],aseptic loosening(RR=2.15,95%CI:0.81-5.70;P=0.13),dislocation rate(RR=0.50;95%CI:0.10-2.47;P=0.39),or infection rate(RR=0.99,95%CI:0.82-1.19;P=0.89),between the uncemented and the cemented long stems for revision THA after mid-term follow-up.CONCLUSION This study has evaluated the mid-term outcomes of both cemented and uncemented stems at first-time revision THA.In summary,there were no significant differences in the dislocation rate,aseptic loosening,intraoperative periprosthetic fracture and infection rate between the two cohorts.

TOTAL KNEE ARTHROPLASTY WITH POSTERIOR CRUCIATE LIGAMENT RETENTION IN PATIENTS WITH SEVERE VARUS DEFORMITY

Objective; TO observe the clinical outcome of total knee arthroplasty (TKA ) with posterior cruciate ligament (PCL ) retention in patients with severe varus deformity. Methods We reviewed the clinical treatment results of primary TKA in patients with severe varus deformity (≥20°) between January 1990 and July 1995. All patients, suffered from ostecoarthritis, were performed on a single surgeon using a minimally constrained "Hybrid" Miller-Galante knees (MG-I). Cliniccal evaluation were assessed by using the Knee Society clinical rating system. The Student’s t test was used to analyse the data. Results At a mean follow-up of 6 years (4-9years), 56 knees in 38 patients were available for review. 5 patients (7 knees) lost follow-up and 3 patients (4 knees) died. The average knee score improved from 33 points before operation to 91 points in the latest follow-up with excellent results in 84% of all patients. The Knee Society functional score improved from 39 to 76 points. The improvements were statistically significant (P < 0. 01 ). A functionally acceptable range of motion (ROM) of more than 90° were achieved in 86% of all patients. Most of cases (50/56 ) had postoperative alignment inside the normal range of 5° to 7° valgus. The other 6 cases had postoperative residual deformity of 5°-10°varus. Total revision rate was 21 % (12 /56 ), the average revision time was 5. 5 years after surgery. Other complications included patellar subluxation in 1 case, anterior pain of knee in 4 cases, and superficial cellulitis in 1 case. No early or late infection, aseptic loosening or anterioposterior instability occurred in this series. Conclusion Severs varus deformity can he successfully corrected at the time of primary TKA by using PCL-retention prosthesis. There were more problems from postoperative medial-lateral instability of knee which contributed significantly to early failure after an average of 6. 0 years.

Bone graft incorporation failure with inappropriate limb load transfer can lead to aseptic acetabular loosening of metal-on-metal prosthesis: A case report

BACKGROUND Aseptic acetabular loosening can result from various factors that can be categorized into groups:patient-related,surgeon-related and implant-related.We present a case of a 63-year-old patient who at first underwent a total hip arthro-plasty(THA)using a metal-on-metal bearing due to hip arthrosis.Follow-up visits revealed no complications after the procedure.Two years after the THA,acetabular component loosening occurred due to subsequent trauma of the opposite hip,necessitating a revision THA using a ceramic-on-ceramic bearing.CASE SUMMARY We aim to illustrate a rare case where the primary reason for undergoing THA revision was not only incomplete bone graft incorporation but also improper limb load distribution.Following the revision arthroplasty,a 9-year follow-up visit revealed improvements in all evaluation measures on questionnaire compared to the state before surgery:Harris Hip Score(before surgery:15;after surgery:95),Western Ontario and McMaster Universities Arthritis Index(before surgery:96;after surgery:0),and Visual Analogue Scale(before surgery:10;after surgery:1).CONCLUSION Opposite-hip trauma caused a weight transfer to the limb after a THA procedure.This process led to a stress shielding effect,resulting in acetabular component loosening.

Application of Acetabular Reinforcement Ring with Hook for Correction of Segmental Acetabular Rim Defects during Total Hip Arthroplasty Revision

This study investigated the biomechanical micro-motion associated with the application of acetabular reinforcement ring with hook （Ganz ring） for the correction of segmental acetabular rim defects, by finite element analysis. The objective was to determine whether the Ganz ring is suitable for correcting segmental acetabular rim defects at different regions during total hip arthroplasty revision as well as the number of screws required to fix the Ganz ring. A finite element model of the hip joint was generated to simulate and evaluate the insertion and fixation of the Ganz ring and acetabular cup in the context of segmental rim defects in the anterior column, superior portion, and posterior column. Micro-motion was the greatest in the posterior column defect and the least in the anterior column defect. However, the peak stress distribution on the remaining portion of the acetabular rim was the highest in the superior portion defect, following the pos- terior column defect and anterior column defect. Increasing the number of fixations of the Ganz ring did not decrease the micro-motion. We found that the Ganz ring effectively provided biomechanical stability during the reconstruction of the segmental rim defect as long as the screws fixed the Ganz ring well to the host bone.

Fracture of Extensively Porous-Coated Cylindrical Femoral Stem Following Revision Total Hip Arthroplasty

Total hip arthroplasty （THA） is one of the most clinically successful surgeries. Despite the prevalence of THA, the number of revisions for septic or aseptic reasons continues to increase.

Unexpected positive cultures including isolation of Propionibacterium acnes in revision shoulder arthroplasty

Objective Little information is available to guide treatment strategies regarding patients with unexpected positive cultures （UPC）,including Propionibacterium acnes （PA）,without overt signs of infection in revision shoulder arthroplasty （RSA）.The purpose of our study was to analyze the prevalence,clinical meaning,treatment and prognosis of UPC in RSA.Data sources and study selection We performed a systematic review of the literature between 1950 and 2013 for all studies reporting on UPC for PA.Studies with the prevalence and prognosis of patients with UPC in RSA were analyzed.Results Six studies meeting our inclusion criteria yielded data for 1 402 patients who underwent a total of 1405 RSA.Based on the available data,following RSA 235 shoulders had UPCs with a pooled percentage of 16.7％ （235/1405）.The most commonly isolated bacteria from shoulders following RSA with UPCs was PA with pooled percentages of 63.4％ （149/235）.Occurrence of true infection from UPCs after RSA was seen in 24 shoulders （24/235,10.2％）.Antibiotic use did not influence the rate of the occurrence of true infection from UPCs （P=0.498）.Conclusions Our study showed a low risk of having a true infection from UPCs after RSA without clinical signs of preoperative infection at the time of the surgery.Therefore,prolonged antibiotic therapy may not be necessary in these patients.

Application of Novel Design Bone Grafting for Treatment of Segmental Acetabular Rim Defects During Revision Total Hip Arthroplasty

The study aimed to develop efficient techniques with different novel graft structures to enhance the treatment of acetabular bone deficiency.The inhomogeneous material properties Finite Element Analysis(FEA)model was reconstructed according to computed tomography images based on a healthy patient without any peri-acetabular bony defect according to the American Academy of Orthopedic Surgeons(AAOS).The FEA model of acetabular bone deficiency was performed to simulate and evaluate the mechanical performances of the grafts in different geometric structures,with the use of fixation implants(screws),along with the stress distribution and the relative micromotion of graft models.The stress distribution mainly concentrated on the region of contact of the screws and superolateral bone.Among the different structures,the mortise-tenone structure provided better relative micromotion,with suitable biomechanical property even without the use of screws.The novel grafting structures could provide sufficient biomechanical stability and bone remodeling,and the mortise-tenone structure is the optimal treatment option for acetabulum reconstruction.

Combination of C-reactive protein and fibrinogen is useful for diagnosing periprosthetic joint infection in patients with inflammatory diseases

Background:The screening of periprosthetic joint infection(PJI)in patients with inflammatory diseases before revision arthroplasty remains uncertain.Serum C-reactive protein(CRP),erythrocyte sedimentation rate(ESR),plasma fbrinogen(FIB),monocyte/lymphocyte ratio,and neutrophil/lymphocyte ratio(NLR)can help screening PJI,but their values in patients with infammatory diseases have not been determined.Methods:Patients with inflammatory diseases who underwent revision hip or knee arthroplasty at West China Hospital,Sichuan University,from January 2008 to September 2020 were divided into infected and non-infected groups based on the 2013 International Consensus Meeting criteria.Sensitivity and specificity of the tested biomarkers for diagnosing infection were determined based on receiver operating characteristic(ROC)curves,and optimal cutoffs were determined based on the Y ouden index.The diagnostic ability of these biomarkers was re-assessed after combining them with each other.Results:A total of 62 patients with inflammatory diseases were studied;of them 30 were infected.The area under the ROC curve was 0.813 for CRP,0.638 for ESR,0.795 for FIB,and 0.656 for NLR.The optimal predictive cutoff of CRP was 14.04 mg/L with a sensitivity of 86.2%and a specificity of 68.7%,while FIB had a sensitivity of 72.4%and a specificity of 81.2%with the optimal predictive cutoff of 4.04 g/L.The combinations of CRP with FIB produced a sensitivity of 86.2%and specificity of 78.1%.Conclusion:CRP with a slightly higher predictive cutoff and FIB are useful for screening PJI in patients with inflammatory diseases,and the combination of CRP and FIB may further improve the diagnostic values.