Revision hip replacement for recurrent Hydatid disease of the pelvis: a case report and review of the literature

A case of a large recurrent hydatid cyst involving the right ilium and right hip treated with excision of the cyst, Total hip replacement and revision of the acetabular component with a Tripolar articulation for cyst recurrence and acetabular component loosening is presented along with a review of the relevant literature. To our knowledge there is no reported case of Total Hip replacement and revision for hydatid disease involving the bony pelvis.     

Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency.

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening.     

High failure rate of bulk femoral head allografts in total hip acetabular reconstructions at 10 years

The authors evaluated the radiographic appearance and functional performance of 30 cemented total hip arthroplasty acetabular reconstructions in 28 patients in whom bulk, weight-bearing, femoral head allografts were used to augment severe acetabular bone deficiency with a mean follow-up period of 10 years (range, 8–13.3 years). The average age of the patients was 51 years. The current study group represents the 10-year subset of a larger series of 38 hip reconstructions previously reported. The graft was bolted within the acetabulum in 12 hips and to the lateral wing of the ilium in the other 18 hips. On average, these grafts supported approximately 60% of the acetabular component. All grafts united. Failure of fixation of the acetabular component occurred in 47% of the acetabular reconstructions (14 hips in 14 patients). Four were diagnosed as loose on the basis of radiographic criteria alone and the other 10 hips had a loose acetabular component at reoperation. Loosening occurred in 58% (7 of 12) of the sockets with intraacetabular graft and in 40% (7 of 18) of those bolted to the lateral ilium. The failure rate of 47% in these reconstructions at 10 years is in sharp contrast to high success rates at less than 5 years and argues against the use of bulk weight-bearing allografts for most situations uncless the only alternative is resection arthroplasty.     

Allograft reconstruction of the acetabulum in revision hip surgery

Acetabular deficiencies seen in revision hip arthroplasty require special attention. Custom components, space-filling cement, relocation of the hip center higher on ilium, and resection arthroplasties have all been used. Allograft reconstruction of acetabular defects has many attractive features, but methods of fixation, long-term success rates, and problems of graft resorption and implant loosening present significant questions. This article presents a classification system for acetabular defects and a surgical technique for correcting them. The results of 218 cementless acetabular reconstructions are reviewed and show the importance of the acetabular rim. When the rim is intact, 97% of reconstructions will remain stable, and 78% of allografts used will consolidate. When the acetabular rim is deficient, special techniques using bulk allograft and internal fixation must be used in order to avoid long-term graft resorption and implant loosening.     

Cross-sectional Anatomy of the Ilium: Implications for Acetabular Component Placement in Total Hip Arthroplasty

Background

High hip center reconstructions, used in revision and complex primary THAs, rely on pelvic bone stock at least 35 mm above the anatomic teardrop. However, the technique does not restore normal hip biomechanics and controversy exists regarding acetabular implant survival. Previous reports document a wide range of implant positioning above the teardrop. There is no anatomic guidance in the literature regarding the amount of bone stock available for initial implant stability in this area of the ilium.

Questions/purposes

We therefore determined the thickness of the human ilium and related it to acetabulum cup coverage in high hip center reconstructions.

Methods

We sectioned 16 cadaveric hips from the anterior superior iliac spine to the anatomic teardrop in 5-mm increments, then measured the thickness of the ilium for each cross section.

Results

The maximum thickness of 42 ± 9 mm occurred at the dome of the acetabulum 35 ± 3 mm above the teardrop. At a distance of 1 cm above the dome, the ilium was reduced by 24%, to 32 ± 6 mm. At 2 cm above the dome, the ilium thickness was 22 ± 4 mm, a 48% reduction from its maximum.

Conclusion

There are substantial anatomic limitations to high hip reconstructions 2 cm above the acetabular dome.     

Injuries of the acetabular triradiate cartilage and sacroiliac joint

Four patients with injuries of the acetabular triradiate cartilage are presented. In three of them premature fusion of the cartilage occurred; two of these developed acetabular deformity and subluxation of the hip. In all patients the sacroiliac joint also was injured; in two, the joint was completely disrupted, leading to fusion and growth disturbance of the ilium. As injury of the triradiate cartilage is easily missed on the initial radiograph, it is advised that all patients with pelvic trauma should be followed clinically and radiographically for at least one year.     

An incomplete periacetabular osteotomy for treatment of neuromuscular hip dysplasia

Standard innominate osteotomies that are recommended for treatment of the typical form of developmental dysplasia of the hip are not recommended for dysplasia associated with neuromuscular disorders. A periacetabular osteotomy that permitted accurate correction of the posterolateral acetabular deficiency was done on 40 patients (50 hips). The purpose of this study was to present the surgical technique, to evaluate whether it can improve acetablular dysplasia, and to provide stable hips. The patients had a mean age of 9.5 years at the time of surgery. The medial cortex of the ilium was left intact, whereas the supraacetabular and retroacetabular cancellous bone, and posterolateral cortical bone were cut. The posterior cut extended down to the triradiate cartilage, or through its former site, respectively. Forty-one hips were evaluated at a mean followup of 5.3 years (range, 2-11.7 years) after surgery. The mean acetabular index improved from 32 degrees preoperatively to 12 degrees at followup. The mean migration percentage improved from 77% to 13%. A redislocation or unstable hip occurred in two patients. According to caregivers, surgery improved personal care, positioning, and comfort. This osteotomy decreases the radius of the elongated acetabulum, provides coverage by articular cartilage particularly at the posterolateral aspect of the acetabulum, and preserves the entire medial wall of the ilium.     

Irritation der Iliopsoassehne nach totalendoprothetischem Hüftgelenkersatz

Chronic irritation of the iliopsoas tendon is a rare cause of persistent pain after total joint replacement of the hip. In the majority of cases, pain results from a mechanical conflict between the iliopsoas tendon and the anterior edge of the acetabular cup after total hip arthroplasty. Pain can be reproduced by active flexion of the hip and by active raising of the straightened leg. In addition, painful leg raising against resistance and passive hyperextension are suggestive of an irritation of the iliopsoas tendon. Symptoms evolve from a mechanical irritation of the iliopsoas tendon and an oversized or retroverted acetabular cup, screws penetrating into the inner aspect of the ilium, or from bone cement protruding beyond the anterior acetabular rim. The diagnosis may be assumed on conventional radiographs and confirmed by CT scans. Fifteen patients with psoas irritation after total hip replacement are reported on. Eleven patients were treated surgically. The acetabular cup was revised and reoriented with more anteversion in six patients, isolated screws penetrating into the tendon were cut and leveled in three patients, and prominent bone cement in conflict with the tendon was resected once. A partial release of the iliopsoas tendon only was performed in another patient. Follow-up examination (range: 11-89 months) revealed that nine patients were free of pain and two patient had mild residual complaints. Psoas irritation in combination with total hip replacement can be prevented by a correct surgical technique, especially with proper selection of the cup size and insertion of the acetabular cup avoiding a rim position exceeding the level of the anterior acetabular rim.     

髋臼加盖技术行全髋关节置换术治疗发育性髋脱位

目的探讨髋臼加盖技术行生物型全髋关节置换术(THA)治疗发育性髋脱位(DDH)的临床疗效。方法采用髋臼加盖技术行生物型THA治疗30例DDH患者(30髋),观察手术前后双下肢长度差异、髋关节旋转中心高度和水平距离、移植骨块与髂骨融合时间,记录术后骨溶解、骨长入、臼杯松动情况,采用Harris髋关节评分(HHS)评价手术疗效。结果患者均获得随访,时间24~60(38.8±16.9)个月。双下肢长度差异由术前11~55(25.3±17.2)mm下降到术后0~12(3.7±3.5)mm(P<0.001),髋关节旋转中心高度由术前35~65(46.1±16.7)mm下降到术后18~30(23.7±5.9)mm(P<0.001),髋关节旋转中心水平距离由术前35~55(42.8±8.9)mm下降到术后18~29(23.3±2.7)mm(P<0.001)。移植骨块与髂骨融合时间5~12(7.7±4.9)个月。HHS由术前39~65(41.8±14.8)分提高到末次随访时84~100(93.5±7.9)分(P<0.001)。至末次随访,无一例出现假体周围骨溶解,假体均获得骨长入固定。结论采用髋臼加盖技术行生物型THA治疗DDH,可获得满意临床疗效。     

An improved acetabular cementing technique in total hip arthroplasty. Aspiration of the iliac wing

We have evaluated the effect of vacuum aspiration of the iliac wing on the osseointegration of cement into the acetabulum. We entered a total of 40 patients undergoing primary total hip arthroplasty into two consecutive study groups. Group 1 underwent acetabular cement pressurisation for 60 seconds before insertion of the acetabular component. Group 2 had the same pressurisation with simultaneous vacuum suction of the ilium using an iliac-wing aspirator. Standard post-operative radiographs were reviewed blindly to assess the penetration of cement into the iliac wing. Penetration was significantly greater in the group with aspiration of the iliac wing.     

The impact of modern cement techniques on acetabular fixation in cemented total hip replacement

A radiographic study was performed to assess acetabular fixation in 78 total hip replacements performed between 1971 and 1980. In 1979, the technique of acetabular component insertion was modified to include water-pik lavage, preservation of subchondral bone of the acetabulum during reaming, multiple fixation holes in the pubis ischium and ilium, and devices that improve pressurization of the cement into the cancellous bone surfaces. The impact of these techniques was studied. A cumulative radiolucency score was calculated for each acetabulum from 5-year follow-up radiographs, and the mean cup radiolucency scores for two chronologic groups were compared using the t-test for independent samples. No significant differences in patient age, weight, or sex, type of prosthesis, or approach used was found between groups. The acetabular components inserted between 1979 and 1980 had significantly lower cup radiolucency scores than those inserted between 1971 and 1978, at 5-year follow-up evaluation. Modern cement technique may be responsible for significantly enhanced durability of acetabular fixation in cemented total hip replacement.     

Pedestal cup operation in acetabular defects after hip cup loosening. A progress report

PURPOSE: An extreme extent of acetabular bone loss makes a primary stable cup fixation very difficult to achieve. No reliable operation method is as yet available. Defect filling with bone cement or bone grafts gives a high long-term failure rate. Further revisions are programmed. METHODS: The titanium pedestal cup possibly offers a solution to these situations. It is fixed in the load-carrying upper vital part of the pelvis. A guide is necessary for this step. The tapered pedestal is reinforced by two large wings for rotational and structural stability. The physiological load transfer goes entirely through the pedestal. Thus, the cup serves only for articulation, sometimes without any contact to bone. Structural bone grafts are not implanted. Due to its modular length the pedestal very often allows a cup position at the original center of rotation. RESULTS: A total of 139 pedestal cups have been implanted. Within a prospective study 51 hip revisions have been followed over 1-5 years. The indications include acetabular defects and resection arthroplasty. Implant related complications were few and consisted of a first generation screw failure and malpositioning of the pedestal. CLINICAL RELEVANCE: After complete removal of all granulomatous tissue and restoration of physiological joint forces we observed early and spontaneous bone regeneration. CONCLUSION: We doubt that a bony reconstruction exclusively happens after massive bone grafting. The acetabulum can recover even in catastrophic cases of pelvic discontinuity without allografts. Nearly all revision cases and rim defects can be managed with the pedestal cup.     

Treatment options for chronic pelvic discontinuity

Chronic pelvic discontinuity is a distinct and unique challenge seen during revision total hip arthroplasty (THA) in which the superior ilium is separated from the inferior ischiopubic segment through the acetabulum, rendering the anterior and posterior columns discontinuous. The operative management of acetabular bone loss in revision THA is one of the most difficult challenges today. Common treatment options include cage reconstruction with bulk acetabular allograft, custom triflange acetabular component, a cup-cage construct, jumbo acetabular cup with porous metal augments, or acetabular distraction with a porous tantalum shell with or without modular porous augments.     

Long-term management results of Pemberton's ilium osteotomy in combination with inter-trochanter derotation-varisation osteotomy in hip dysplasia of childhood

AIM: The aim of the present study was to obtain long-term functional and radiographic results after a pericapsular osteotomy of the ilium (Pemberton) and a simultaneously performed derotation-varisation osteotomy of the proximal femur in children with developmental dysplasia of the hip (DDH) after the end of the maturity process. METHOD: The clinical results and x-ray measurements of 79 patients with 100 operated hips were analysed. The average follow-up time after surgery was 14 years and 7 months (range: 10.4 to 19.5 years). The indication for operation was determined using the acetabular angle of more than two standard deviations. RESULTS: The clinical investigation shows that 85 % of the operated patients had no functional limitations. 14 % of the patients had minor limitations and 1 % had major limitations in their hip movement. No patient suffered constant hip pain; 62 % had no pain even after long walking; 32 % had pain after walking for more than an hour; 6 % complained of hip pain after walking for less than an hour. The radiological measurements show that 95.9 % of the patients had normal or mildly pathological ACM angle scores, and 92.8 % had normal or mildly pathological CE angle scores. CONCLUSION: Surgical treatment of residual hip dysplasia by simultaneously performed pericapsular ilium and proximal femur osteotomy is very effective. Although a radiographically almost normal acetabulum could be documented in patients after the end of the maturity process, revalgisation of the proximal femur occurred. With an appropriate acetabular correction additional osteotomy of the femur might therefore be unnecessary.     

Using intraoperative pelvic landmarks for acetabular component placement in total hip arthroplasty

Dislocation after total hip arthroplasty is frequently due to acetabular malpositioning. Positioning of the acetabular component using anatomical landmarks may reduce the incidence of dislocation from improper acetabular orientation. The pelvis provides 3 bony landmarks (ilium, superior pubic ramus, and superior acetabulum), which, when used to define a plane, allows cup orientation in abduction and version. Landmarks evaluated in 24 cadaveric acetabuli allowed slightly increased abduction and anteversion of the cup, compared with native acetabuli. Six hundred seventeen primary total hip arthroplasties were performed between 1996 and 2003 using this technique. Mean cup abduction was 44.4 degrees with 13.2 degrees of anteversion. This technique allows satisfactory reproducible cup orientation based on individual pelvic morphology. Review of patient outcome data suggest high patient satisfaction and lower dislocation rate without additional equipment, time, or cost.     

Ultrasound hip evaluation in achondroplasia

BACKGROUND: During the period from 1985 to 2006, 22 children (44 hips) affected by achondroplasia were ultrasonographically evaluated. METHODS: The patients' age at examination ranged from 7 days to 29 months. The hip ultrasound (US) examination was performed, according to Graf's method, using a Siemens Sonoline sonogram with linear 5.0- and 7.5-MHz probes. In all the hips, the alpha angle was impossible to be measured because the medial margin of the ilium was not ultrasonographically detectable. The ultrasonographic findings included the following: configuration of the acetabular bony rim, configuration of the acetabular roof, echogenicity of the head and acetabular cartilage, bony coverage percentage of the femoral head according to Morin et al, beta angle according to Graf, dynamic hip instability, and presence of the proximal femoral ossific nucleus. RESULTS: All hips had a sharp acetabular bony rim, a horizontal acetabular roof, thickened acetabular cartilage, and normal echogenicity. The femoral head was well centered and deeply contained in the acetabular fossa. The mean coverage was 86.7% (range: 78%-90%) and showed progressively larger values with increasing age. The mean value of the beta angle was 20 degrees (range: 8 degrees-38 degrees). The value of the beta angle tended to decrease as age increased. No difference was observed between the right and the left hip in both measurements. All hips were stable. The ossific nucleus was present in 5 children. CONCLUSIONS: The characteristic findings in hip ultrasonography in children with achondroplasia can aid in its early diagnosis because ultrasound can anatomically detect the altered development of the achondroplastic acetabulum.     

Revision of the acetabular component without cement after a previous acetabular reconstruction with use of a bulk femoral head graft in patients who had congenital dislocation or dysplasia. A follow-up note

BACKGROUND: Revision of an acetabular component that has failed after a total hip arthroplasty in which a bulk femoral head autogenous graft or allograft was used as a structural graft for acetabular reconstruction is an uncommon but complex and challenging procedure. We previously reported the results for seventy hips at an average of 16.5 years after a total hip arthroplasty in which an acetabular reconstruction had been performed with a femoral head graft. In the present study, we evaluated a subset of nine hips from that series that had a subsequent revision of the acetabular component without cement. The purpose of the current study was to assess the usefulness of the bone graft in this revision. METHODS: The nine patients (nine hips) were followed clinically and radiographically for an average of seventy-six months (range, sixty-one to 114 months) after the index revision. In six hips the autogenous femoral head graft previously had been bolted to the lateral side of the ilium, and in one hip the femoral head allograft had been affixed in this manner. In the two remaining hips, the allograft had been placed within the acetabulum. The hips were classified according to the extent of acetabular bone loss, with use of criteria described previously. Three hips had stage-I bone loss; four, stage-II; and two, stage-IIB. A porous-coated hemispherical acetabular component was inserted without cement and fixed with screws in each hip. At least 70 percent of the porous coating was in contact with viable bone. RESULTS: At the time of the latest follow-up after the index revision, all nine acetabular components were functioning well without loosening or osteolysis and none had been revised. The average Harris hip score was 77 points (range, 61 to 98 points) compared with 49 points (range, 27 to 96 points) preoperatively. One hip had had revision of the femoral stem, and another had had exchange of the acetabular liner because of recurrent dislocations. There was no additional resorption of the residual bulk graft that was in contact with the metal shell in any hip. CONCLUSIONS: In this small series of complex acetabular revisions, the healed bulk graft provided valuable additional bone stock for the support of an acetabular component that was inserted without cement. Insertion of the acetabular component into the available bone, which consisted in major part of host bone and in minor part of united revascularized bulk graft, resulted in a well functioning hip after an intermediate duration of follow-up. In all except two hips, the enlarged bone stock allowed insertion of a larger acetabular component than had been used previously.     

髋臼粉碎性骨折合并压缩性缺损的治疗与对策

目的探讨治疗髋臼粉碎性骨折合并压缩性缺损的手术方法.方法1997年7月～2005年2月,收治髋臼粉碎性骨折合并压缩性缺损43例,其中陈旧性骨折25例,新鲜骨折16例,畸形（大于90 d）2例;复杂骨折与缺损34例,简单骨折与缺损9例.缺损体积3～9 cm^3,平均4.5cm^3.采用改良髋臼入路,应用髋臼三维记忆内固定系统（ATMFS）三维记忆锁定碎骨;髋臼碎骨关节面整复法;自体髂骨髋臼后壁解剖性重建法;自体骨＋人工骨填塞及骨腊隔离法等术后相关措施.结果所有患者随访5～86个月,平均15.7个月.粉碎骨折关节面粉碎＋填补压缩体积至头臼解剖复位31例;自体髂骨后壁“解剖性重建头臼解剖复位”12例;40例患者经过平均5.3个月患侧髋关节功能达到健侧水平,1例股骨头缺血性坏死,2例异位骨化＋股骨头缺血性坏死导致髋关节骨融合.结论本文介绍了治疗髋臼粉碎性骨折合并压缩性缺损的新方法与措施,有效地提高了股骨头与髋臼解剖对应率,为髋关节功能的恢复提供了新的思路.     

Acetabular augmentation using a glass-ceramic block: 3 patients followed 3-4 years

We have developed a block of glass-ceramic to augment the dysplastic acetabulum. 3 patients with acetabular dysplasia underwent implantation of a block of glass-ceramic on the lateral surface of the ilium just above the hip joint. The patients did not require immobilization and returned to their daily lives, walking without a cane 4 weeks after the operation. The mean Harris hip score was 47 points preoperatively and 94 points 3 years postoperatively.     

A new modified technique of triple osteotomy of the innominate bone for acetabular dysplasia

A new modified technique of triple osteotomy of the innominate bone has been devised and implemented for the treatment of residual acetabular dysplasia in children with developmental dysplasia of the hip. The procedure is done through a two-incision approach. The ischium, pubis, and iliac bones are osteotomized, with resection of a triangular wedge of bone from the outer cortex of the proximal part of the ilium. The resection of the triangular wedge of bone from the outer cortex alone creates a slot with the intact inner cortex serving as a stabilizing abutment where the distal posterior aspect of the ilium fits. This osteotomy allows for extensive coverage of the femoral head with greater stability. The stable construct of the osteotomy and pelvic fixation facilitates early weight bearing and obviates the need for hip spica cast immobilization. Since its conception the new triple osteotomy has been done in 11 children (13 hips). The preoperative vertical center edge angle of Weiberg was 8.9 degrees (range, 5 degrees -17 degrees ). The postoperative vertical center edge angle was a mean of 45.6 degrees (range, 31 degrees -58 degrees ). The last followup vertical center edge angle was a mean of 44.9 degrees (range, 29 degrees -58 degrees ). The mean preoperative acetabular angle of Sharp was 53 degrees (range, 48 degrees -61 degrees ). The postoperative acetabular angle was a mean of 25.4 degrees (range, 19 degrees -40 degrees ). The last followup acetabular angle was a mean of 28 degrees (range, 18 degrees -41 degrees ). All patients went on to have bony unions on their innominate bone. We describe the technique for the osteotomy and presents preliminary results of all patients who had the procedure.