Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.     

Favorable results of acetabular reconstruction with impacted morsellized bone grafts in patients younger than 50 years: a 10- to 18-year follow-up study of 34 cemented total hip arthroplasties

We report a long-term review of 41 acetabular reconstructions using impacted morsellized bone grafts and a cemented total hip arthroplasty (THA) in patients younger than 50 (22-49; average 38) years. Reconstruction was performed in 23 primary THA (19 patients) and 18 revision THA (17 patients). 3 patients were lost to follow-up and 3 (4 hips) died within 10 years of surgery; none had a revision. Thus, 34 hips (30 patients) were reviewed with an average follow-up of 13 (10-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component 7 and 11 years after surgery. One additional cup was revised after 12 years during a femoral stem revision due to wear and matching problems, but was well fixed. The survival rate of the acetabular reconstruction technique was 94% (95% CI: 90-98%).     

Favorable results of acetabular reconstruction with impacted morsellized bone grafts in patients younger than 50 years: A 10- to 18-year follow-up study of 34 cemented total hip arthroplasties

We report a long-term review of 41 acetabular reconstructions using impacted morsellized bone grafts and a cemented total hip arthroplasty (THA) in patients younger than 50 (22-49; average 38) years. Reconstruction was performed in 23 primary THA (19 patients) and 18 revision THA (17 patients). 3 patients were lost to follow-up and 3 (4 hips) died within 10 years of surgery; none had a revision. Thus, 34 hips (30 patients) were reviewed with an average follow-up of 13 (10-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component 7 and 11 years after surgery. One additional cup was revised after 12 years during a femoral stem revision due to wear and matching problems, but was well fixed. The survival rate of the acetabular reconstruction technique was 94% (95% CI: 90-98%).     

Results of the anatomic medullary locking total hip arthroplasty at a minimum of twenty years. A concise follow-up of previous reports

Between October 1982 and December 1984, the senior author performed 223 total hip arthroplasties in 215 patients with use of the anatomic medullary locking hip stem and TriSpike cup. We now report on 119 of these hips at a mean of 22.0 years (range, 20.0 to 25.0 years) after surgery. Of the fifty-six hips with minimum twenty-year follow-up radiographs and the original acetabular component, seventeen (30.4%) had pelvic osteolytic lesions measuring larger than 1.5 cm(2). Of the sixty-eight hips with twenty-year radiographs and the original anatomic medullary locking stem, twenty-five (36.8%) had femoral osteolytic lesions measuring larger than 1.5 cm(2). Acetabular osteolysis was significantly associated with cup loosening (p = 0.006), but the presence of femoral osteolysis was not associated with stem loosening. Kaplan-Meier analysis, with revision for any reason as the end point, revealed that the survival rate at twenty years was 85.8% +/- 5.2% for the acetabular shell and 97.8% +/- 2.2% for the stem. The most common reoperation was polyethylene exchange because of wear or osteolysis.     

Acetabular reconstruction with bone impaction grafting and a cemented cup: 20 years' experience.

Acetabular bone stock loss compromises the outcome in primary and revision total hip arthroplasty. In 1979, a biologic method was introduced with tightly impacted cancellous allografts in combination with a cemented polyethylene cup for acetabular reconstruction. With this technique, it is possible to replace the loss of bone and to repair normal hip mechanics and hip function with a standard implant. Based on the authors' 20 years experience, a review of the long-term data is presented in primary total hip arthroplasty with preexisting acetabular bone stock loss, primary total hip arthroplasty in rheumatoid arthritis, patients who had bone impaction when younger than 50 years, and in acetabular revisions. The survival rate with revision of the cup for aseptic loosening as the end point was 94% at 10 to 17 years, 90% at 10 to 18 years, 91% at 10 to 17 years, and 92% at 10 to 15 years. From biopsy specimens from humans and histologic data in animal experiments the incorporation of these impacted bone chips was proven. The acetabular bone impaction technique using large morselized bone chips (range, 0.7-1 cm) and a cemented cup is a reliable technique with favorable long-term outcome.     

Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up

BACKGROUND: Acetabular revision in patients with rheumatoid arthritis is often difficult because of the poor quality and quantity of the acetabular bone stock. The purpose of this study was to evaluate the midterm clinical and radiographic outcomes of acetabular revision with use of an impaction bone-grafting technique and a cemented polyethylene cup. METHODS: Thirty-five consecutive acetabular revisions were performed with impaction bone-grafting and use of a cemented cup in twenty-eight patients with rheumatoid arthritis. The average age at the revision was fifty-seven years. The minimum duration of follow-up of all reconstructions that were still functioning or that were followed until the time of death was three years (mean, 7.5 years; range, three to fourteen years). No patient was lost to follow-up, but five patients (six hips) died before the time of the review. The acetabular bone defects were classified as cavitary in twelve hips and as combined segmental-cavitary in twenty-three. RESULTS: The five patients (six hips) who died had been doing well at the time of their latest follow-up. Of the remaining patients, six (six hips) had a repeat revision. The average Harris hip score of the living patients with a surviving implant at the time of follow-up was 82 points, and there was no or only mild pain in twenty-one of the twenty-three hips. Radiographic analysis of all twenty-nine hips that had not been revised showed loosening in one hip and a nonprogressive radiolucent line in one zone in two others. Kaplan-Meier analysis demonstrated a prosthetic survival rate, with aseptic loosening as the end point, of 90% at eight years. CONCLUSION: Acetabular revision with impaction bone-grafting and a cemented cup in patients with rheumatoid arthritis had acceptable results at an average of 7.5 years postoperatively.     

Total hip arthroplasty with cement and without acetabular bone graft for severe hip dysplasia. A concise follow-up, at a minimum of twenty years, of a previous report

We previously evaluated a cohort of fifty-three patients with severe hip dysplasia (Crowe Type-II, III, or IV subluxation) who underwent a total of sixty-six Charnley total hip arthroplasties. The acetabular component was placed at the anatomic hip center, the superolateral defect was filled with cement, and no bone-grafting was used to supplement the acetabular wall. All but one patient, who was lost to follow-up, were followed until death or for a minimum of twenty years. Radiographic and functional follow-up data were collected prospectively. This retrospective review included twenty-four patients (thirty-four hips) who were alive at a minimum of twenty years following the surgery. Fourteen (22%) of the sixty-five hips underwent revision of a component, with eleven of the revisions performed because of aseptic loosening. Eight of those eleven hips underwent revision because of acetabular loosening alone; two, because of femoral loosening alone; and one, because of loosening of both components. The combined prevalence of revision because of aseptic loosening of the acetabular component and radiographic evidence of failure of the acetabular component was 28% (eighteen hips). With the numbers available, the need for acetabular revision was not associated with the percentage of cement coverage (p = 0.362) or the Crowe classification (p = 0.159). At a minimum of twenty years postoperatively, the survivorship of the acetabular component was 86% +/- 8% with revision because of aseptic loosening as the end point and 82% +/- 10% with revision because of aseptic loosening or radiographic evidence of loosening as the end point. The results that we evaluated at a minimum of twenty years after use of this technique can be compared with the results of other techniques in studies with similar long-term follow-up periods.     

Acetabular revision with impacted freeze-dried cancellous bone chips and a cemented cup: a report of 7 cases at 5 to 9 years' follow-up

The long-term results of bone impaction grafting with fresh-frozen femoral head allografts and a cemented cup are favorable. Because of intermittent shortage of fresh-frozen femoral heads at our local bone bank, we used processed freeze-dried bone in 7 acetabular revisions operated between 1989 and 1994. All 7 consecutive patients were followed annually. At final review (March 2000), 1 patient had died after 8.5 years of follow-up of a cause not related to the surgery. In 1 hip, a rerevision was performed for septic loosening 5 years after the previous septic loosening. Radiographically the freeze-dried allografts seemed to incorporate in all cases but the reinfected one; progressive radiolucent lines were not seen, although 1 case had a stable line in 1 zone. The overall survival rate for the 7 acetabular reconstructions at an average follow-up of 7 years (range, 5-9 years) was 86%. At midterm follow-up, there was no aseptic loosening. In this limited case report, the results at midterm for freeze-dried allograft bone chips in acetabular reconstructions are acceptable.     

Acetabular revision with extensive allograft impaction and uncemented hydroxyapatite-coated implants. Results after 9 (7-11) years follow-up

This is a clinical and radiographic review of 87 hips in 79 patients 9 (7-11) years after acetabular revision with extensive use of morselized allograft firmly impacted into localized defects as well as the entire acetabular cavity, followed by insertion of an uncemented hydroxyapatite-coated cup with supplementary screw fixation. The 9-year survival rate for the acetabular implant was 90.5% (95% CI, 83.4%-97.6%) with revision for any reason as end point and 94% (95% CI, 89%-99.1%) with revision for aseptic loosening as end point. Acetabular revision with massive allograft impaction and hydroxyapatite-coated implants show very promising results. The limited contact between implant and host bone does not seem to compromise implant survival in the 7- to 11-year perspective.     

Long-term survival of the acetabular component after total hip arthroplasty with cement in patients with developmental dysplasia of the hip

BACKGROUND: Total hip arthroplasty with cement remains a difficult procedure in patients with osteoarthritis secondary to developmental dysplasia of the hip as it is associated with high rates of aseptic loosening of the acetabular component. The purpose of the present study was to evaluate the rate of revision of the acetabular component in this group of patients and the variables that are associated with it. METHODS: We retrospectively reviewed the records and radiographs of 292 hips in 206 patients who had undergone total hip arthroplasty with cement for the treatment of osteoarthritis secondary to developmental dysplasia of the hip. The average age of the patients at the time of the index procedure was 42.6 years, and the average duration of follow-up was 15.7 years (range, 2.2 to 31.2 years). Fourteen patients were lost to follow-up, and seven patients died from causes unrelated to surgery. A 22.25-mm head was used in all cases, and bone-grafting of the acetabulum was performed in forty-eight hips. Survival of the acetabular component was calculated with revision for aseptic loosening as the end point. Individual survival rates based on age, component type, previous surgery, and annual polyethylene wear also were calculated. RESULTS: The most common reason for revision was aseptic loosening of the acetabular component, which led to 87.2% of the revision procedures. The overall rate of survival of the acetabular component was 90.6% at ten years and 63% at twenty years. A higher rate of acetabular revision was noted in association with previous acetabular surgery, the offset-bore cup, younger age, and accelerated polyethylene wear (p < 0.05 for all comparisons). CONCLUSIONS: Aseptic loosening of the acetabular component affects the longevity of total hip replacements in patients with osteoarthritis secondary to developmental dysplasia of the hip. The present study identified the risk factors associated with the long-term survival of the acetabular component in this group of patients.     

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. A 15- to 20-year follow-up

This study presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients, at a mean of 16.5 years follow-up (15 to 20). The Kaplan-Meier survivorship for the cup with end-point revisions for any reason, was 79% at 15 years (95% confidence interval (CI); 67 to 91). Excluding two revisions for septic loosening at three and six years, and one revision of a well-fixed cup after 12 years in the course of a femoral revision, the survivorship was 84% at 15 years (95% CI; 73 to 95). At review there were no additional cases of loosening, although seven acetabular reconstructions showed radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.7 cm to 1.0 cm) and a cemented cup, is a reliable technique of reconstruction, when assessed at more than 15 years.     

Acetabular revision with allograft bone. 103 revisions with 3 reconstruction alternatives, followed for 0.3-13 years.

We reviewed 103 consecutive acetabular revisions in 92 patients, for whom allograft bone and 1 of 3 alternative acetabular components had been used: Harris-Galante cup (HGC, 38 hips), Müller acetabular roof reinforcement ring (ARR, 39 hips), or Burch-Schneider antiprotrusio reinforcement cage (APC, 26 hips). The mean follow-up was 4.5 (0.3-13) years. 7 HGCs, 1 ARR, and 1 APC required revision because of aseptic loosening. Using the endpoint revision because of such loosening, the HGC gave 73% survival after 8 years, the ARR 89% after 13 years, and the APC 94% after 11 years. Using a worst-case criterion, survival was 69% for the HGC after 8 years, 84% for the ARR after 13 years, and 83% for the APC after 11 years. Radiographic incorporation of the allograft, no resorption of the allograft, use of a bulk allograft, male gender, and implantation of a reinforcement device were associated with a lower mechanical failure rate. Good durability of allograft bone in reconstructions of bone deficiencies in acetabular revision surgery can be expected when the implant can bridge the temporary period of mechanical weakness of the allograft. Therefore, in severe acetabular deficiencies, reinforcement devices with sufficiently stable fixation in the host bone should be preferred.     

Low Revision Rates at More Than 10 Years for Dual-Mobility Cups Cemented Into Cages in Complex Revision Total Hip Arthroplasty

BackgroundInstability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability.MethodsThis is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; Serf, Décines-Charpieu, France) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation.ResultsWith a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients.ConclusionThe use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years.     

Extra-large uncemented hemispherical acetabular components for revision total hip arthroplasty

BACKGROUND: Extra-large uncemented components provide several advantages for acetabular revision, but limited information is available on the results of their use. The purpose of this study was to evaluate, at a minimum of five years, the results associated with the use of an extra-large uncemented porous-coated component for acetabular revision in the presence of bone loss. METHODS: Eighty-nine extra-large uncemented hemispherical acetabular components were used for revision after aseptic failure of a total hip arthroplasty in forty-six men and forty-three women (mean age at revision, fifty-nine years; range, thirty to eighty-three years). The revision implant (a Harris-Galante-I or II cup fixed with screws) had an outside diameter of > or = 66 mm in men and > or = 62 mm in women. Seventy-nine patients had a segmental or combined segmental and cavitary acetabular bone deficiency before the revision. Particulate bone graft was used in fifty-four hips and bulk bone graft, in nine. RESULTS: One patient died with the acetabular component intact and two patients were lost to follow-up within five years after the operation. At the time of the last follow--up, four acetabular components had been removed or revised again (two for aseptic loosening). All of the remaining patients were followed clinically for at least five years (mean, 7.2 years; range, 5.0 to 11.3 years). In the hips that were not revised again, only two sockets had definite radiographic evidence of loosening. All four of the sockets that loosened were in hips that had had combined cavitary and segmental bone loss preoperatively. In the hips that were not revised again, the mean modified Harris hip score increased from 56 points preoperatively to 83 points at the time of the most recent follow-up. The most frequent complication, dislocation of the hip, occurred in eleven patients. The probability of survival of the acetabular component at eight years was 93% (95% confidence interval, 85% to 100%) with removal for any reason as the end point, 98% (95% confidence interval, 92% to 100%) with revision for aseptic loosening as the end point, and 95% (95% confidence interval, 88% to 100%) with radiographic evidence of loosening or revision for aseptic loosening as the end point. CONCLUSIONS: This study demonstrates that extra-large uncemented components used for acetabular revision in the presence of bone loss perform very well and have a low rate of aseptic loosening at the time of intermediate-term follow-up.     

Cementless acetabular fixation at fifteen years. A comparison with the same surgeon's results following acetabular fixation with cement

BACKGROUND: Loosening of the acetabular component is the major long-term problem associated with total hip arthroplasty with cement. The purpose of the present study was to evaluate the minimum thirteen-year results associated with cementless acetabular components that had been inserted by a single surgeon and to compare them with the results associated with cemented acetabular components that had been inserted by the same surgeon. METHODS: One hundred and twenty consecutive, nonselected primary total hip replacements were performed in 108 patients with use of a Harris-Galante-I cementless acetabular component and a cemented femoral component with a 28-mm head. The patients were evaluated clinically with use of a standard terminology questionnaire, and they were evaluated radiographically for loosening, component migration, wear, and osteolysis. The rates of revision for aseptic loosening and radiographic evidence of loosening for this cohort were compared with the rates for four previously reviewed consecutive series of hips in which the acetabular component had been inserted with cement. All patients were managed by the same surgeon, were followed for thirteen to fifteen years, and were evaluated with use of the same two criteria (revision and loosening) as the end points for Kaplan-Meier analysis. RESULTS: Sixty-six patients (seventy-two hips) were living and forty-two patients (forty-eight hips) had died after thirteen to fifteen years of follow-up. No acetabular component had been revised because of aseptic loosening, and no acetabular component had migrated. With revision of the acetabular component for any reason as the end point, the survival rate was 81% +/- 8% at fifteen years. With revision of the acetabular component for clinical failure (osteolysis, wear, loosening, or dislocation) as the end point, the survival rate was 94% +/- 8% at fifteen years. Among the seventy hips with at least thirteen years of radiographic follow-up, five had pelvic osteolysis and three had had revision of a well-fixed acetabular component because of pelvic osteolysis secondary to polyethylene wear. The mean linear wear rate was 0.15 mm/yr (0.12 mm/yr when one outlier was excluded). CONCLUSIONS: In terms of fixation, Harris-Galante-I cementless acetabular components performed better than did cemented 22-mm-inner-diameter Charnley acetabular components as well as 28-mm-inner-diameter all-polyethylene and metal-backed acetabular components that had been inserted by the same surgeon. However, the rate of wear was greater in association with the Harris-Galante-I cementless components than it was in association with the Charnley cemented all-polyethylene components.     

Cementless hemispheric hydroxyapatite-coated sockets for acetabular revision

This study describes our experience with a hydroxyapatite-coated uncemented hemispherical component used for revision of 72 patients with aseptic loosening of the acetabular component. Preoperative Paprosky classification of the acetabular defects was 1 type I, 35 type II, and 36 type III; according to American Academy of Orthopaedic Surgeons, 14 segmental, 10 cavitary, and 48 combined. The mean follow-up was 7.6 years (range, 5.0-13.0). Complications were seen in 7 cases (9.6%). Seventy acetabular components (97.2%) showed bone ongrowth on the radiographs. The survival rate was 90.8% after a mean follow-up of 7.6 years (range, 5.0-13.0) when revision for any reason is the end point (confidence interval, 80.5%-100%) and 98.1% (confidence interval, 94.5%-100%) when aseptic loosening of the cup is the end point. We conclude that hydroxyapatite-coated cups for acetabular revision show promising results.     

Acetabular component revision with frozen massive structural pelvic allograft: average 5-year follow-up

We evaluated the use of a hemipelvic acetabular transplant in 20 revision hip arthroplasties with massive acetabular bone defects. We report 65% good intermediate-term results at a mean follow-up of 5 years (4-10 years). A cemented cup (without a reinforcement ring) was entirely supported by the allograft in all procedures. There were 7 failures (5 aseptic loosening and 2 deep infections). Two dislocations occurred but did not require acetabular revision. There were 2 cases in which moderate acetabular migration occurred but then stabilised and did not progress. Thirteen of 20 acetabular reconstructions did not require revision. We believe that these are satisfactory intermediate-term results for massive acetabular defects too large for reconstruction with other standard techniques.