Complications Rate and Hip Function After Revision of Infected Hip Arthroplasty with Bone Defects using Bone Allografts: A Systematic Review and Meta-Analysis

Document Type : SYSTEMATIC REVIEW

Authors

1 Orthopedics Research Centre, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

2 Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran

3 Department of Epidemiology, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran

4 Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran

10.22038/abjs.2025.90232.4092

Abstract

Objectives: We performed a systematic review and meta-analysis to evaluate complication rates and hip function following the revision of infected hip arthroplasty with bone defects using bone allografts.
Methods: A comprehensive search of the PubMed, Web of Science, Embase, and Cochrane Library databases was conducted up to January 2024 to identify pre-post clinical trials. The primary outcomes assessed were the risk of reinfection, a critical concern for surgeons, and hip functional scores. The methodological quality of the included studies was also evaluated. A weighted mean difference (WMD) with a 95% confidence interval (CI) was used as the pooled estimate for clinical outcomes through random-effects meta-analysis, accounting for heterogeneity across studies.
Results: Of the 2,189 records retrieved, 12 pre-post clinical trials (with fair to good quality) were included in the meta-analysis, involving a total of 342 participants. The pooled mean difference in Harris Hip Score (HHS) was 36.86 (95% CI: 29.58 to 44.13) post-surgery. In a subgroup analysis of studies employing structural grafts, the HHS increased by 36.99 (95% CI: 29.56 to 44.42). The overall reinfection rate was 6%. Subgroup analysis revealed that in studies utilizing morselized and structural allografts, the reinfection rates were 6% and 3%, respectively. The overall mean rate of aseptic loosening was 5%. Subgroup analysis showed that in studies using morselized grafts, the rate of aseptic loosening was 4%. The incidence of dislocation was 2% in the morselized group and 5% in the structural group.
Conclusion: Revision of infected hip arthroplasty with bone defects using bone allografts may improve hip function. Interestingly, morselized allografts are often associated with higher rates of reinfection. Additionally, our findings suggest that structural allografts are associated with increased dislocation rates compared to morselized allografts. This difference may be attributed to the larger and more complex defects that necessitated the use of structural allografts rather than morselized grafts.
        Level of evidence: III

Keywords

Main Subjects


  1. Gross AE, Wong P, Saleh KJ. Don't throw away the ring: Indications and use. J Arthroplasty. 2002;17(4):162-166. doi.org/10.1054/arth.2002.32464.
  2. Guntin J, Serino J, Rossi D, Boniello A, Gusho CA, Della Valle CJ. Hypoalbuminemia increases mortality after two-stage revision total joint arthroplasty. Arch Bone Jt Surg. 2023;11(3):173. doi.org/10.22038/ABJS.2022.65148.3123.
  3. Del Gaizo DJ, Kancherla V, Sporer SM, Paprosky WG. Tantalum augment for Paprosky IIIA defects remains stable at midterm follow-up. Clin Orthop Relat Res. 2012;470:395-401. doi: 10.1007/s11999-011-2170-x
  4. Salvati EA, Chekofsky KM, Brause BD, Wilson Jr PD. Reimplantation in infection: a 12-year experience. Clin Orthop Relat Res. 1982;170:62-75.
  5. Lee J-M, Nam H-T. Acetabular Revision Total Hip Arthroplasty Using an Impacted Morselized Allograftand a Cementless Cup: Minimum 10-Year Follow-Up. J Arthroplasty. 2011;26(7):1057-1060. doi.org/10.1016/j.arth.2011.03.035.
  6. Boldt JG, Dilawari P, Agarwal S, Drabu KJ. Revision total hip arthroplasty using impaction bone grafting with cemented nonpolished stems and Charnley cups. J Arthroplasty. 2001;16(8):943-952. doi.org/10.1054/arth.2001.25559.
  7. Piccaluga F, Della Valle AG, Fernández JE, Pusso R. Revision of the femoral prosthesis with impaction allografting and a Charnley stem: a 2-to 12-year follow-up. J Bone Joint Surg Br. 2002;84(4):544-549. doi.org/10.1302/0301-620X.84B4.0840544.
  8. Berry DJ, Chandler HP, Reilly DT. The use of bone allografts in two-stage reconstruction after failure of hip replacements due to infection. J Bone Joint Surg Am. 1991;73(10):1460-8.
  9. Buttaro MA, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty Article. Journal of Bone and Joint Surgery - Series B. 2005;87(3):314-319. doi:10.1302/0301-620X.87B3.14788
  10. English H, Timperley AJ, Dunlop D, Gie G. Impaction grafting of the femur in two-stage revision for infected total hip replacement. J Bone Joint Surg Br. Jul 2002;84(5):700-5. doi:10.1302/0301-620x.84b5.12504
  11. Nestor BJ, Hanssen AD, Ferrer-Gonzalez R, Fitzgerald Jr RH. The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection. JBJS. 1994;76(3):349-359.
  12. Morscher E, Babst R, Jenny H. Treatment of infected joint arthroplasty. Int Orthop. 1990;14:161-165. doi.org/10.1007/BF00180122.
  13. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 2015;4:1-9. doi.org/10.1186/2046-4053-4-1.
  14. Unfried RI, Krause LMF, Cezimbra HM, Pacheco LS, Larangeira JA, Ribeiro TA. A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction. Clin Med Insights Arthritis Musculoskelet Disord. 2022;15:11795441221090344. doi:10.1177/11795441221090344
  15. Ammon P, Stockley I. Allograft bone in two-stage revision of the hip for infection: is it safe? The Journal of Bone & Joint Surgery British Volume. 2004;86(7):962-5.
  16. Winkler H, Stoiber A, Kaudela K, Winter F, Menschik F. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. The Journal of Bone & Joint Surgery British Volume. 2008;90(12):1580-4.
  17. Nusem I, Morgan DA. Structural allografts for bone stock reconstruction in two-stage revision for infected total hip arthroplasty: good outcome in 16 of 18 patients followed for 5–14 years. Acta orthopaedica. 2006;77(1):92-7.
  18. Lee PT, Clayton RA, Safir OA, Backstein DJ, Gross AE. Structural allograft as an option for treating infected hip arthroplasty with massive bone loss. Clinical Orthopaedics and Related Research®. 2011;469(4):1016-23.
  19. Wang J-W, Chen C-E. Reimplantation of infected hip arthroplasties using bone allografts. Clinical Orthopaedics and Related Research (1976-2007). 1997;335:202-10.
  20. Hsieh P-H, Shih C-H, Chang Y-H, Lee M, Yang W-E, Shih H-N. Treatment of deep infection of the hip associated with massive bone loss: two-stage revision with an antibiotic-loaded interim cement prosthesis followed by reconstruction with allograft. The Journal of Bone & Joint Surgery British Volume. 2005;87(6):770-5.
  21. Elbers JB, Leijtens B, van Werven HE, Sturm PD, Kullberg BJ, Schreurs BW. Antibiotic mixing through impacted bone grafts does not seem indicated in two-stage cemented hip revisions for septic loosening. Hip International. 2014;24(6):596-603.
  22. Ilyas I, Morgan D. Massive structural allograft in revision of septic hip arthroplasty. International orthopaedics. 2001;24(6):319-22.
  23. Alexeeff M, Mahomed N, Morsi E, Garbuz D, Gross A, Latner A. Structural allograft in two-stage revisions for failed septic hip arthroplasty. The Journal of Bone & Joint Surgery British Volume. 1996;78(2):213-6.
  24. Badarudeen S, Shu AC, Ong KL, Baykal D, Lau E, Malkani AL. Complications after revision total hip arthroplasty in the medicare population. The Journal of Arthroplasty. 2017;32(6):1954-8.
  25. Gamradt SC, Lieberman JR. Bone graft for revision hip arthroplasty: biology and future applications. Clinical Orthopaedics and Related Research (1976-2007). 2003;417:183-94.
  26. Strahl A, Boese CK, Ries C, Hubert J, Beil FT, Rolvien T. Outcome of different reconstruction options using allografts in revision total hip arthroplasty for severe acetabular bone loss: a systematic review and meta-analysis. Archives of orthopaedic and trauma surgery. 2023;143(10):6403-22.
  27. Logoluso N, Pedrini FA, Morelli I, De Vecchi E, Romanò CL, Pellegrini AV. Megaprostheses for the revision of infected hip arthroplasties with severe bone loss. BMC surgery. 2022;22(1):68.
  28. Wimmer MD, Hischebeth GT, Randau TM, Gathen M, Schildberg FA, Fröschen FS, et al. Difficult-to-treat pathogens significantly reduce infection resolution in periprosthetic joint infections. Diagnostic Microbiology and Infectious Disease. 2020;98(2):115114.
  29. George DA, Drago L, Scarponi S, Gallazzi E, Haddad FS, Romano CL. Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification. World journal of orthopedics. 2017;8(5):400.
  30. Akgün D, Perka C, Trampuz A, Renz N. Outcome of hip and knee periprosthetic joint infections caused by pathogens resistant to biofilm-active antibiotics: results from a prospective cohort study. Archives of orthopaedic and trauma surgery. 2018;138(5):635-42.
  31. Corona PS, Vicente M, Lalanza M, Amat C, Carrera L. Use of modular megaprosthesis in managing chronic end-stage periprosthetic hip and knee infections: Is there an increase in relapse rate? European Journal of Orthopaedic Surgery & Traumatology. 2018;28(4):627-36.
  32. Wafa H, Grimer R, Reddy K, Jeys L, Abudu A, Carter S, Tillman R. Retrospective evaluation of the incidence of early periprosthetic infection with silver-treated endoprostheses in high-risk patients: case-control study. The bone & joint journal. 2015;97(2):252-7.
  33. Romanò CL, Malizos K, Capuano N, Mezzoprete R, D'Arienzo M, Der CV, et al. Does an antibiotic-loaded hydrogel coating reduce early post-surgical infection after joint arthroplasty? Journal of bone and joint infection. 2016;1(1):34-41.
  34. Capuano N, Logoluso N, Gallazzi E, Drago L, Romanò CL. One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surgery, Sports Traumatology, Arthroscopy. 2018;26(11):3362-7.
  35. Ullmark G, Hallin G, Nilsson O. Impacted corticocancellous allografts and cement for femoral revision of total hip arthroplasty using Lubinus and Charnley prostheses. The Journal of arthroplasty. 2002;17(3):325-34.
  36. Schreurs B, Keurentjes J, Gardeniers J, Verdonschot N, Slooff T, Veth R. Acetabular revision with impacted morsellised cancellous bone grafting and a cemented acetabular component: a 20-to 25-year follow-up. The Journal of Bone & Joint Surgery British Volume. 2009;91(9):1148-53.