RESUMO
AIMS: The Corail stem has good long-term results. After four years of using this stem, we have detected a small group of patients who have presented with symptomatic metaphyseal debonding. The aim of this study was to quantify the incidence of this complication, to delineate the characteristics of patients presenting with this complication and to compare these patients with asymptomatic controls to determine any important predisposing factors. PATIENTS AND METHODS: Of 855 Corail collarless cementless stems implanted for osteoarthritis, 18 presented with symptomatic metaphyseal debonding. A control group of 74 randomly selected patients was assembled. Clinical and radiological parameters were measured and a logistic regression model was created to evaluate factors associated with metaphyseal debonding. RESULTS: The prevalence of this complication was 2.1% in our series. In the multivariable model, the presence of a Dorr B-type proximal femur was associated with metaphyseal debonding (odds ratio (OR) 10.73, 95% confidence interval (CI) 2.31 to 49.97, p = 0.002), as was a body mass index > 25 kg/m2 (OR 6.85, 95% CI 1.06 to 44.28, p = 0.04). Smaller stems and the use of a polyethylene acetabular liner appeared to be protective when compared with metal and ceramic setting hard-on-hard bearings. CONCLUSION: We have described an uncommon but important mode of failure of the Corail stem. Surgeons should be aware of this phenomenon; overweight patients with Dorr B-type femurs and in whom hard bearings are used appear to be particularly at risk. Cite this article: Bone Joint J 2017;99-B:1435-41.
Assuntos
Artroplastia de Quadril/instrumentação , Prótese de Quadril , Osteoartrite do Quadril/cirurgia , Falha de Prótese , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Falha de Prótese/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: To determine the effects of tranexamic acid (TXA) on transfusions in patients undergoing hip replacement with a hybrid or cementless prosthesis. METHODS: A group of 172 consecutive patients aged 18 years or older who underwent elective hip replacement with uncemented or hybrid prostheses, undergoing surgery between January 2012 and January 2014 by the same primary surgeon and anesthesiologist, were retrospectively included. TXA (1 g) was administered immediately before incision in the TXA group. Primary variables included number of red blood cell transfusions and the influence of TXA for each type of prosthesis. Secondary variables included hematocrit at discharge, length of hospital stay, thrombosis or pulmonary embolism, seizures, and death. RESULTS: Average transfusion was 1.53 units/patient in the control group compared to 0.6 units/patient in the TXA group (z = 6.29; U = 1640.5; p < 0.0001). TXA use was significantly correlated with the number of units transfused (p < 0.0001, 95% CI -1.24 to -0.68). Odds risk reduction for transfusion was observed during surgery (OR: 0.14; CI 0.06-0.29; p < 0.0001) and during the rest of hospital stay (OR: 0.11; CI 0.01-0.96; p = 0.046). Both hybrid and cementless prostheses that received TXA were transfused less than control groups (0.57 ± 1 vs. 1.7 ± 1 p < 0.01 and 0.65 ± 1 vs. 1.24 ± 1 p < 0.01). No difference was observed between the groups regarding adverse effects. Hematocrit values at discharge and length of hospital stay were similar between groups. No deaths were observed during hospital stay. CONCLUSIONS: TXA reduced transfusions without increasing the prevalence of adverse effects. This reduction was observed during surgery and the following days of hospital stay for both for hybrid and cementless prosthesis.
Assuntos
Artroplastia de Quadril/estatística & dados numéricos , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Pré-Medicação/estatística & dados numéricos , Ácido Tranexâmico/administração & dosagem , Idoso , Antifibrinolíticos/administração & dosagem , Argentina/epidemiologia , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Causalidade , Estudos de Coortes , Comorbidade , Feminino , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Prevalência , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
We determined the midterm survival, incidence of peri-prosthetic fracture and the enhancement of the width of the femur when combining struts and impacted bone allografts in 24 patients (25 hips) with severe femoral bone loss who underwent revision hip surgery. The pre-operative diagnosis was aseptic loosening in 16 hips, second-stage reconstruction in seven, peri-prosthetic fracture in one and stem fracture in one hip. A total of 14 hips presented with an Endoklinik grade 4 defect and 11 hips a grade 3 defect. The mean pre-operative Merle D'Aubigné and Postel score was 5.5 points (1 to 8). The survivorship was 96% (95% confidence interval 72 to 98) at a mean of 54.5 months (36 to 109). The mean functional score was 17.3 points (16 to 18). One patient in which the strut did not completely bypass the femoral defect was further revised using a long cemented stem due to peri-prosthetic fracture at six months post-operatively. The mean subsidence of the stem was 1.6 mm (1 to 3). There was no evidence of osteolysis, resorption or radiolucencies during follow-up in any hip. Femoral width was enhanced by a mean of 41% (19% to 82%). A total of 24 hips had partial or complete bridging of the strut allografts. This combined biological method was associated with a favourable survivorship, a low incidence of peri-prosthetic fracture and enhancement of the width of the femur in revision total hip replacement in patients with severe proximal femoral bone loss.
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Artroplastia de Quadril/métodos , Reabsorção Óssea/cirurgia , Transplante Ósseo/métodos , Fêmur/cirurgia , Adulto , Idoso , Artroplastia de Quadril/efeitos adversos , Reabsorção Óssea/diagnóstico por imagem , Reabsorção Óssea/etiologia , Cimentação , Métodos Epidemiológicos , Feminino , Fêmur/diagnóstico por imagem , Fêmur/patologia , Prótese de Quadril , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas Periprotéticas/etiologia , Falha de Prótese , Radiografia , Reoperação/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Fractures occurring at or near the distal tip of a hip prosthesis with a stable femoral stem (Vancouver type-B fractures) are associated with many complications because of the inherently unstable fracture pattern. Locking compression plates use screws that lock into the plate allowing multiple points of unicortical fixation. Such unicortical fixation may lower the risk of damage to the cement mantle or a stable femoral stem during the treatment of a periprosthetic femoral fracture. The purpose of this study was to analyze clinically and radiographically a group of patients with a Vancouver type-B1 periprosthetic femoral fracture treated with open reduction and internal fixation with use of a locking compression plate. METHODS: Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1 periprosthetic femoral fracture were treated with a locking compression plate. There were five men and nine women with an average age of sixty-eight years at the time of fracture. All of the fractures occurred after a total hip arthroplasty performed with cement, and eleven of the arthroplasties were revisions. In addition to the plate, cortical strut allografts were used to stabilize five fractures. The patients were assessed clinically and radiographically. RESULTS: The average duration of follow-up was twenty months. Eight fractures healed uneventfully at an average of 5.4 months. Three treatment constructs failed with fracture of the plate within twelve months after surgery. An additional three constructs also failed because of plate pullout. All failures except one occurred in constructs in which a cortical strut allograft had not been utilized. CONCLUSIONS: On the basis of the high failure rate in this series of patients, locking compression plates do not appear to offer advantages over other types of plates in the treatment of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the cement mantle, the locked screws did not appear to offer good pullout resistance in this fracture type. We believe that supplementation with strut allografts should be used routinely if this type of locking compression plate is selected to treat these fractures.
Assuntos
Placas Ósseas , Fraturas do Fêmur/cirurgia , Prótese de Quadril , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril , Parafusos Ósseos , Transplante Ósseo/métodos , Deambulação Precoce , Desenho de Equipamento , Falha de Equipamento , Feminino , Fraturas do Fêmur/classificação , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Consolidação da Fratura/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Suporte de Carga/fisiologiaRESUMO
Advancement or separation of the apex hole eliminator screw in uncemented Duraloc 100 cups (DePuy, Warsaw, Indiana, USA) has been recently reported as a radiographic finding without clinical effects. We report 4 patients with a separation of the apex hole eliminator screw in Duraloc 300 uncemented cups and aseptic failures of a hybrid total hip arthroplasty (acetabular osteolysis and femoral stem loosening). Revision surgery was performed when disabling pain and radiographic signs of loose components were present. Although difficult to determine, a relationship between the screw migration and the failure could have existed in these cases. Migration of the screw might not only be interpreted as a radiographic, clinically irrelevant finding. Its presence should alert the orthopaedic surgeon that the prosthesis is exposed to high intraarticular fluid pressures.
RESUMO
Vancomycin-supplemented allografts provide biological restoration of bone stock and sound fixation with a low incidence of re-infection. Experimental incorporation of these grafts is similar to allografts without vancomycin. However, the underlying biology remains unknown. We report the first histological observations of vancomycin-supplemented impacted bone allografts in two reconstructions performed 14 and 20 months after revision surgery because of a periprosthetic fracture. Areas of active bone remodelling (creeping substitution), as well as calcified bone trabeculae and graft particles embedded in dense fibrous tissue, were observed with osteoid and fibroconnective tissue surrounding polymethylmethacrylate particles. These pathological findings are similar to those reported in allografts without vancomycin and support the hypothesis that high levels of vancomycin do not affect the incorporation of bone graft.
Assuntos
Antibacterianos/administração & dosagem , Artroplastia de Quadril/métodos , Transplante Ósseo/métodos , Prótese de Quadril/efeitos adversos , Infecções Relacionadas à Prótese/patologia , Vancomicina/administração & dosagem , Idoso , Remodelação Óssea/fisiologia , Calcinose/patologia , Fibrose/patologia , Humanos , Masculino , Infecções Relacionadas à Prótese/diagnóstico por imagem , Radiografia , Reoperação , Transplante HomólogoRESUMO
Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard, cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection.