Structural Allograft as an Option for Treating Infected Hip Arthroplasty with Massive Bone Loss

Abstract

Background Revision of the infected hip arthroplasty with major bone loss is difficult. Attempts to restore bone stock with structural allograft are controversial. Questions/purposes We assessed the (1) reinfection rate; (2) rerevision rate; (3) radiographic graft union, resorption, and implant migration; (4) Harris hip scores at 1 year and at last followup compared with before surgery; and (5) other major complications associated with the use of bulk structural allograft to treat massive bone loss in infected hip arthroplasty. Methods We retrospectively reviewed 27 patients who underwent two-stage revision arthroplasty using structural allograft to treat massive bone defects in infected hip arthroplasty. There were 17 proximal femoral grafts, three acetabular major column grafts, two acetabular minor column grafts, and 10 cortical strut grafts used. Five patients had combinations of two allografts. The minimum followup was 1.1 years (mean, 8.2 years; range, 1.1-16.8 years). Results One of 27 patients had reinfection. The KaplanMeier survivorship was 93% at 10 years with rerevision for aseptic loosening as the end point. Radiographically, three patients had nonunion at the graft-host junction. All patients except two had graft resorption, of which all were mild except two, which were severe. Three patients had implant migration. The mean modified Harris hip scores were 39.2 points (range, 25-60) preoperatively, 67.3 points (range, 40-91) at 1-year followup, and 70.3 points (range, 46-81) at last followup. Other major complications included one patient with dislocation and one patient with transient sciatic nerve injury.

Two-stage Treatment of Hip Periprosthetic Joint Infection Is Associated With a High Rate of Infection Control but High Mortality

“…Synthetic models have favored a direct exchange approach [34]; however, pooled clinical data have demonstrated the superiority of the two-stage protocol over a period of decades [7,15]. A staged protocol has been applied with control of infection in the setting of massive bone loss [16], resistant organisms [17], and when used with oral [3] and abbreviated courses of intravenous antibiotics [33]. The use of high-dose antibiotic-laden cement spacers for the first-stage operation has yielded infection control rates superior to those with resection arthroplasty alone [2]; although this has not been a uniformly consistent finding [26,30], it is the most commonly reported approach.…”

Radiography versus Multidetector Computed Tomography in Assessing Graft Integration after Acetabular Reconstruction

“…28,29 The use of structural allografts provides adequate support and transforms uncontained acetabular defects to contained ones and achieves satisfactory outcome, 7,8,20,30 with a revision rate of up to 7% at 10 years. 31 Nonetheless, poor midto-long-term outcome has also been reported, with revision rates ranging from 33 to 60%. 3,32,33 To improve outcome, adding bone substitute material to the allograft 34 and supercharging the structural allografts with mesenchymal stem cells 35 have been proposed.…”

“…Radiographic evaluation of graft integration is prone to interobserver error 31 and overestimation. 37 Radiography tends to magnify the extent of host-graft healing and incorporation at the interface.…”

Management of infection after total hip arthroplasty

“…Richards et al 33 reported good success with a novel technique that uses an antibiotic cement-loaded Küntscher nail cemented with a highly polished femoral stem as a temporary spacer in the setting of massive femoral bone loss. 34 Infected periprosthetic fractures represent a combination of two entities that each present a unique set of challenges. 34 Infected periprosthetic fractures represent a combination of two entities that each present a unique set of challenges.…”