Massive Bone Defect Compromises Postoperative Cup Survivorship of Acetabular Revision Hip Arthroplasty with Impaction Bone Grafting

We evaluated 66 acetabular revision arthroplasties using cemented cup with impaction bone grafting (IBG) to detect the extent that bone defect affects the outcome. We defined the maximum acetabular defect distance (MADD), which indicates the greatest depth of the grafted layer. Cup survival analysis with aseptic loosening as the endpoint revealed that the “MADD ≤ 20 mm” group showed higher survivorship than the “MADD > 20 mm” group (95% vs. 74%, P = 0.034), and that the simple-wall-defect group (none or one mesh used) showed higher survivorship than the complex-wall-defect group (two meshes used) (96% vs. 73%, P = 0.044). A favorable indication for acetabular IBG reconstruction is cases in which those cups can be placed at ≤ 20 mm MADD with a simple wall defect.     

Autogenous Impaction Grafting in Total Hip Arthroplasty with Developmental Dysplasia of the Hip

Autogenous impaction grafting was performed to improve acetabular cup coverage in 68 patients (78 hips) with developmental dysplasia of the hip (DDH) after total hip arthroplasty, and the patients were then monitored for a mean duration of 5.5 years. No cup revisions were required, and there was no radiographic loosening. The host–graft interface became indistinct by 6 weeks after surgery, trabecular bone formation was seen by 12 weeks, and definite trabecular reorientation was seen by 20 months. At the last follow-up examination, the mean cup coverage was 97.7%, whereas mean coverage by bone grafting was 27.9%. Among 12 patients with most of the bone graft placed at the absolutely protruded area of the cup, the cup coverage provided by the bone graft decreased from 95.4% immediately after surgery to 20.7% by the final follow-up examination. Bone-particle grafting can provide a satisfactory integration speed and a low incidence of displacement and ectopic ossification.     

A 2- to 16-Year Clinical Follow-Up of Revision Total Hip Arthroplasty Using a New Acetabular Implant Combined With Impacted Bone Allografts and a Cemented Cup

Background

Treatment of acetabular bone loss with impaction bone grafting (IBG) at revision total hip arthroplasty is highly dependent on mechanical stability and graft compression for clinical success. Here, we describe a new technique to further compress and stabilize the acetabular graft bed with a thin, perforated titanium shell.

Extended Trochanteric Osteotomy Followed by Cemented Impaction Allografting in Revision Hip Arthroplasty

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.     

成人髋臼发育不良全髋置换的髋臼重建

目的探讨应用全髋关节置换术治疗髋臼发育不良继发骨性关节炎时臼杯假体安放的方法及其对手术疗效的影响。方法对48例(56髋)髋臼发育不良行全髋置换时,部分应用髋臼内陷成形术向内或内下方加深髋臼并选择小型臼杯假体。通过Ranawat三角测量术前及术后股骨头中心距理想旋转中心的水平和垂直距离,应用Mark髋臼四分法判断臼杯假体的实际位置。行Harris临床评分及X线检查做为疗效判定标准。结果Ranawat三角测量,术前股骨头中心距理想旋转中心的水平距离平均为18.2 mm,术后为1.52 mm;术前垂直距离平均为10.26 mm,术后为5.68 mm。手术前后比较,差异有统计学意义(P<0.01)。Mark髋臼四分区中,臼杯假体位于内侧区者为46髋,其中内下区34髋。术前Harris评分为32.5～60.3分,术后为76.6～96.5分。无假体松动和移位,无翻修病例。结论在髋臼发育不良行全髋置换的髋臼重建中,应强调向内方或内下方加深髋臼,接近于真臼安放臼杯假体,以尽量恢复髋关节理想旋转中心;选择小型臼杯假体以获得髋臼宿主骨的良好覆盖,减少髋臼植骨的机会。     

Mid-term Follow-up of the Direct Anterior Approach in Acetabular Revision Hip Arthroplasty Using a Reconstruction Cage With Impaction Grafting

BackgroundSevere acetabular bone loss is often treated with reconstruction cages and impaction grafting using allograft bone. Accurate implant positioning is crucial for successful clinical and radiological outcomes. The direct anterior approach (DAA) is a standard approach for primary total hip arthroplasty (THA) that is being used more frequently for revision THA. The aim of this study was to report midterm clinical and radiological outcomes of acetabular revision arthroplasty using the DAA to address large acetabular defects by using a reconstruction cage and impaction grafting.MethodsAcetabular cup revisions were performed in 64 patients (64 hips) with severe acetabular bone loss. All patients received reconstruction cages with impaction grafting via the DAA. The stem was also revised in 22 patients. Complications, radiological, and functional outcomes were assessed.ResultsSix of the 64 patients were revised at a mean follow-up of 27.6 months (range, 11-84 months), two each for implant failure, infection, and recurrent dislocation. One hip showed the radiological failure of the implant, but the patient was asymptomatic and was not revised. The median Western Ontario McMasters Osteoarthritis Score (WOMAC) for the cohort overall improved significantly (P < .01) by the latest follow-up compared with preoperative scores.ConclusionGood midterm outcomes can be obtained with the DAA for acetabular cup revisions done to address severe acetabular bone loss by using reconstruction cages and impaction grafting. The number of complications was within the expected range for this type of revision procedure at midterm follow-up, and dislocation rates were low.     

Constrained Acetabular Liners Cemented Into Cages During Total Hip Revision Arthroplasty

The combination of acetabular bone loss and hip instability is challenging. Sixteen patients underwent revision total hip arthroplasty using constrained acetabular liners cemented into cages. The average follow-up was 28 months (range, 24-60 months). Clinical evaluation was obtained using the Harris hip score along with radiographic data. At latest follow-up, 13 patients were available for evaluation. Although the average postoperative Harris hip score was 62 points, which was better than the preoperative score of 27 points, the overall radiographic failure rate was 23%. The combination of poor acetabular bone stock and altered stresses from the increased constraint likely led to the poor outcome. We would only recommend use of a cemented, constrained acetabular liner in combination with a protrusio cage as a bail out or salvage procedure.     

Survivorship Analysis of Eighty Revised Hip Arthroplasties With the Impaction Grafting Technique Using Whole Femoral Head Allografts With the Articular Cartilage

Background

Acetabular impaction bone grafting aims to restore anatomy in hip revision surgery. This is an effective but expensive and time-consuming technique. Usually, the articular cartilage is removed from the femoral head allograft. We aimed to reproduce the same results retaining the cartilage of the allograft.

Reconstruction of Acetabular Defects With Impaction Grafting in Primary Cemented Total Hip Arthroplasty Produces Favorable Results: Clinical and Radiographic Outcomes Over 6.4 Years on Average

BackgroundCemented primary total hip arthroplasty (THA) associated with acetabular reconstruction (AR) involving impacted bone grafting has been employed successfully in the revision of cavitary defects but the results are reportedly less predictable for segmental defects. The objective of the study is to evaluate the clinical and radiographic results of patients who had presented cavitary, segmental, and combined acetabular defects and received THA/AR involving impacted morselized cancellous bone autografts followed by rigorous postoperative management.MethodsClinical outcomes were assessed retrospectively of 154 patients who had been submitted to 169 THA/AR procedures performed by a single surgeon over a 15-year period. The Harris Hip Score system was applied to 103 patients, and the degree of acetabular migration was determined from radiograph images of 91 AR procedures, of which 40 were segmental/combined and 51 were cavitary reconstructions.ResultsThe frequency of aseptic acetabular loosening was 3% while that of thromboembolic events was 4.1%. According to Harris Hip Score, 87.4% of outcomes were classified as excellent/good after an average follow-up period of 6.4 years irrespective of the type of acetabular defect. Horizontal and/or vertical acetabular migrations and changes in angular tilt were observed in all ARs, although the minor movements detected did not undermine the structural stability of the reconstructions or the functional capacity of patients.ConclusionThe described THA/AR technique can be used effectively in the reconstruction of segmental/combined and cavitary acetabular defects. The success of the technique as applied to segmental/combined defects was attributed in part to the rigorous rehabilitation protocol with temporary postoperative weight-bearing restriction.     

Favorable Early Results of Impaction Bone Grafting With Reinforcement Mesh for the Treatment of Paprosky 3B Acetabular Defects

Background

We present the early institutional experience with the use of impaction bone grafting, mesh augmentation, and cement fixation of an all-polyethylene cup for the treatment of Paprosky 3B acetabular defects during revision total hip arthroplasty.

全髋关节置换术治疗晚期髋臼发育不良

目的探讨全髋关节置换术治疗晚期髋臼发育不良致髋关节骨关节炎时人工髋臼的安放方法。方法对2002年1月至2008年1月因髋臼发育不良导致骨关节炎行全髋关节置换术的病例进行随访,有52例(60髋)获得随访。其中男6例,女46例;年龄46~72岁,平均62岁;双髋8例,单髋44例。主要症状为疼痛及跛行。在行人工全髋置换术时,根据髋臼发育不良的程度,采用了加深髋臼、髋臼内陷及髋臼外上缘植骨等三种方法。术后随访应用H arris评分进行髋关节功能评价,术后第3、6、9、12个月及以后每1年以同等条件投照双髋关节正位X线片,观察髋臼假体与髋臼骨床愈合的情况。随访2~8年,平均4年6个月。结果加深髋臼和髋臼内陷的病例,髋臼假体与髋臼骨床接触良好,无松动,关节功能恢复优良。而髋臼外上缘植骨的6髋中有5髋,术后2年时植骨块与髋臼假体间出现透亮带,但髋臼假体无松动。结论髋臼发育不良导致髋关节骨关节炎的病例在施行人工关节置换术时应根据髋臼骨床的情况采用不同的手术方式安放人工髋臼。在髋臼底部骨质较多的情况下,应采用加深髋臼的方法。加深髋臼后仍有少量髋臼假体外露时可采用髋臼内陷安放人工髋臼。髋臼外上缘结构植骨的患者仍需长期随访观察。     

Impaction Grafting Is Sufficient to Address Acetabular Deficiency During Total Hip Arthroplasty of Most Dysplastic Hips With Over 30% Bone Defect

BackgroundAddressing acetabular deficiency during arthroplasty of dysplastic hips is challenging. We assessed outcomes of a protocol for choosing either impaction or structural graft for this purpose.MethodsThis retrospective study included 59 patients (71 hips) with a dysplastic hip and over 30% uncoverage that underwent cementless total hip arthroplasty. Morselized impaction grafting was performed for hips where initial stability of the acetabular cup was achieved. In others, a shelf graft was inserted before implantation of the acetabular cup. Outcomes were assessed at a minimum follow-up of 4 years.ResultsFifty-seven (80.3%) hips underwent impaction grafting and 14 (19.7%) received a structural graft. Mean age at surgery was 48.1 ± 13.5 (18-68) years for impaction and 48.6 ± 14 (24-70) years for shelf grafts. Mean increase in Harris Hip Score was 51.5 ± 9.3 and 50 ± 11.2 for the impaction and structural groups, respectively, at a mean follow-up of 92 (49-136) months (P = .6). Heterotopic ossification occurred in 16 patients in the impaction group vs none in the structural group (P = .004). Radiologically, mean percentages of cup coverage provided by the graft were 47.8 ± 10.9% and 48.9 ± 13.3% in the impaction and structural groups, respectively (P = .75). All but one of shelf grafts united to host bone and all impaction grafts incorporated. There was one case of cup loosening in the structural graft group.ConclusionMost dysplastic acetabula with over 30% defect can be addressed using a cementless cup and impaction grafting, with good results in the midterm. In about 20% of cases, initial press-fit is not attainable and structural support-like shelf graft becomes necessary.Level of evidenceIV.     

Acetabular Reconstruction With the Medial Protrusio Technique for Complex Primary and Revision Total Hip Arthroplasties

Background

In the setting of acetabular deficiency during total hip arthroplasty (THA), the medial protrusio technique (MPT) allows for increased component coverage while avoiding excessive component abduction or elevation of the hip center. The technique involves controlled reaming through the medial acetabular wall while maintaining the continuity of the anterior and posterior columns. The purpose of this study is to analyze the results of the largest reported series to date of primary and revision THAs using the MPT.

Uncemented Porous Tantalum Acetabular Components: Early Follow-Up and Failures in 613 Primary Total Hip Arthroplasties

Uncemented tantalum acetabular components were introduced in 1997. The purpose was to determine the 2- to 10-year results with this implant material in primary total hip arthroplasty. Our registry identified all primary total hip cases with porous tantalum cups implanted from 1997 to 2004. Clinical outcomes and radiographs were studied. 613 cases were identified. Seventeen percent of patients were lost to follow-up. Twenty-five reoperations were performed (4.4%). Acetabular cup removal occurred in 6 cases (1.2%). No cups were revised for aseptic loosening. Incomplete radiolucent lines were found on 9.3% of initial postoperative radiographs. At 2 years, 67% had resolved. Zero new radiolucent lines were detected. Two- to 10-year results of porous tantalum acetabular components for primary total hip arthroplasty demonstrate high rates of initial stability and apparent ingrowth.     

应用特殊髋臼钢板结合植骨技术治疗全髋翻修术中髋臼骨缺损

目的 探讨髋臼钢板结合植骨治疗髋臼骨缺损的临床效果.方法 应用髋臼钢板结合植骨治疗20例髋臼骨缺损髋臼骨缺损按AAOS分型,其中Ⅰ型2例,Ⅱ型4例,Ⅲ型14例.术前髋关节Harris评分平均37.6分,术后根据临床及X线进行评估.结果 所有患者均采用该方法重建髋臼,术后髋部顽固性疼痛1例,原因可能是髋臼周缘发生异位骨化.经服用强效止痛药物1年后好转.其余病例无并发症,平均随访3年,Harris评分平均86.4分.X线片示无一例患者的髋臼骨床、移植骨、重建钛板和聚乙烯内衬交界面出现透亮带.结论 髋臼钢板结合植骨可为假体提供坚强的初始固定,具有恢复髋关节旋转中心的作用.可有效修复髋臼骨缺损.     

Impaction Bone Grafting Combined with Titanium Mesh for Acetabular Bone Defects Reconstruction in Total Hip Arthroplasty Revision: A Retrospective and Mini‐Review Study

ObjectiveTo investigate the application of impaction bone grafting (IBG) combined with Ti‐alloy mesh for acetabular bone defect reconstruction in total hip arthroplasty (THA) revision and follow up the clinical outcomes and imaging findings.MethodsThe clinical and imaging data of patients who were admitted to our hospital from January 2000 to December 2020 and underwent acetabular bone defects reconstruction using IBG combined with titanium mesh were retrospectively analyzed. Preoperative and post‐revision Oxford and Harris scores, and post‐revision complications were evaluated. Radiographs were used to determine center of rotation (COR) of the hip joint, transparency line, bone graft fusion, and bone mineral density (BMD) around the hip joint.ResultsSignificant improvement was observed in both Oxford and Harris scores (P < 0.05). The radiographs taken at the last follow‐up examination showed no significant differences in the acetabulum COR, offsets, inclination angle, mean ratio of vertical value, and BMD analysis between the post‐revision side and contralateral side (P > 0.05). The follow‐up data showed restoration of the mesh implant and graft bone fusion.ConclusionsThe application of IBG combined with titanium‐alloy mesh in revision THA patients with acetabular defects was found to provide satisfactory outcomes. However, large‐scale studies are still needed to further elucidate the long‐term outcomes.