RESUMEN
BACKGROUND: Primary revisions using cement without bone graft reconstruction are less frequently used because of their supposed higher failure rate. The results, in fact, depend on multiple parameters: number of prior revisions, cementing technique quality, and residual bone stock; these intricate factors are rarely taken together into account when analyzing this treatment method. HYPOTHESIS: Femoral component fixation with cement can be a valid option in total hip arthroplasty primary revision. OBJECTIVES: The objective of this investigation was to study the long-term results of cemented femoral stems in total hip arthroplasty primary revisions in terms of the quality of the cementing technique and the residual bone stock. PATIENTS AND METHODS: This is a retrospective study of a series of 80-cemented primary femoral stems revised for aseptic loosening using a new-cemented femoral stem without bone graft. Seventy implants were analyzed at the longest follow-up. The Postel Merle D'Aubigné and the Harris Hip Scores were used for clinical assessment. The French Academy SOFCOT 99 bone loss grading system was used to classify preoperative bone compromise severity. The Barrack classification assessed the quality of the postoperative cementation. The radiographic study at the last follow-up sought signs of femoral implant loosening classified according to Harris. RESULTS: The mean follow-up was 10 years and 10 months. The functional evaluation of the hip showed a significant overall gain (p<0.0001) after surgical revision. In our series, the existence of severe grade III or IV bone loss on the SOFCOT 99 classification exposed the patient to a significant risk of intraoperative complications (p=0.03). The grade III and IV femurs had a significantly higher risk (p=0.0001) of having type C or D cementation according to the Barrack classification. Type D cementation was a risk factor for significant iterative radiographic loosening (p=0.005) compared to A, B or C cementations. The 10-year survival rate of the femoral implant was 90% (95% confidence interval [95% CI]: 79.2-94.9%). This survival rate was significantly better (p=0.0016) for revisions with type A or B cementations on the Barrack scale (96% survival; 95% CI: 85.1-99%) than for type C or D (70% survival; 95% CI: 41.4-86.1%). CONCLUSION: This study shows that revised cemented femoral stems without bone graft added are a valid therapeutic option in primary cemented total hip arthroplasty revisions provided that a good-quality cement technique can be achieved. Sufficient bone stock (SOFCOT 99 grade 0, I or II) was indispensable for good cementation. LEVEL OF EVIDENCE: IV: therapeutic retrospective study.
Asunto(s)
Artroplastia de Reemplazo de Cadera/métodos , Cementos para Huesos/uso terapéutico , Cementación/métodos , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Trasplante Óseo , Cementación/efectos adversos , Femenino , Fémur , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE OF THE STUDY: Two-stage reimplantation remains the most popular solution for infected total knee arthroplasty. We have used articulated spacers since their introduction in 2000. We evaluated tolerance, joint motion under general anesthesia before reimplantation and also the infectious and functional long-term outcome. MATERIAL AND METHODS: Between June 2000 and April 2003, we implanted an articulated spacer in 28 patients who required revision of their total knee arthroplasty. Postoperatively, contact weight bearing was allowed with unlimited knee motion depending on pain control. Mean time between implant removal and reimplantation was eight weeks (range 6-16 weeks). RESULTS: There was one dislocation due to excessive play between the two components. Passive joint motion before reimplantation was 53 degrees (range 5-80 degrees ). At last follow-up, 24 patients were free of overt infection and all antibiotic regimens had been discontinued for at least 20 months (20-48 months). Two patients required a second two stage revision. One had an arthrodesis and in one only suppressive antibiotic therapy was possible. DISCUSSION: Spacer removal appears easy at reimplantation. Good knee flexion (greater than 40 degrees in ten patients and greater than 60 degrees in eight) facilitated exposure, avoiding the need for tilting of the tibial tuberosity in seven patients. Functional and infectious outcomes were similar to those reported in the literature. CONCLUSION: The spacer appears to improve patient comfort between the two operations. It also facilitates the reimplantation procedure because of the easier exposure and greater knee flexion compared with a mono-bloc spacer or an external fixator. There must however be enough bone stock to hold the articulated spacer in place.